De-implementing wisely: developing the evidence base to reduce low-value care

Jeremy M Grimshaw, Andrea M Patey, Kyle R Kirkham, Amanda Hall, Shawn K Dowling, Nicolas Rodondi, Moriah Ellen, Tijn Kool, Simone A van Dulmen, Eve A Kerr, Stefanie Linklater, Wendy Levinson, R Sacha Bhatia, Jeremy M Grimshaw, Andrea M Patey, Kyle R Kirkham, Amanda Hall, Shawn K Dowling, Nicolas Rodondi, Moriah Ellen, Tijn Kool, Simone A van Dulmen, Eve A Kerr, Stefanie Linklater, Wendy Levinson, R Sacha Bhatia

Abstract

Choosing Wisely (CW) campaigns globally have focused attention on the need to reduce low-value care, which can represent up to 30% of the costs of healthcare. Despite early enthusiasm for the CW initiative, few large-scale changes in rates of low-value care have been reported since the launch of these campaigns. Recent commentaries suggest that the focus of the campaign should be on implementation of evidence-based strategies to effectively reduce low-value care. This paper describes the Choosing Wisely De-Implementation Framework (CWDIF), a novel framework that builds on previous work in the field of implementation science and proposes a comprehensive approach to systematically reduce low-value care in both hospital and community settings and advance the science of de-implementation.The CWDIF consists of five phases: Phase 0, identification of potential areas of low-value healthcare; Phase 1, identification of local priorities for implementation of CW recommendations; Phase 2, identification of barriers to implementing CW recommendations and potential interventions to overcome these; Phase 3, rigorous evaluations of CW implementation programmes; Phase 4, spread of effective CW implementation programmes. We provide a worked example of applying the CWDIF to develop and evaluate an implementation programme to reduce unnecessary preoperative testing in healthy patients undergoing low-risk surgeries and to further develop the evidence base to reduce low-value care.

Keywords: evaluation methodology; health services research; healthcare quality improvement; implementation science; patient-centred care.

Conflict of interest statement

Competing interests: EK serves as a clinical consultant for BIND Benefits Inc.; JMG holds a CIHR Tier 1 Canada Research Chair in Knowledge Transfer and Uptake and has a CIHR Foundation Grant (FDN-143269); WL is Chair of Choosing Wisely Canada.

© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

Figures

Figure 1
Figure 1
Choosing Wisely De-Implementation Framework with preoperative testing example.

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