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

• Published in: BMJ quality & safety Vol. 29; no. 5; pp. 409 - 417
• Main Authors: Grimshaw, Jeremy M, Patey, Andrea M, Kirkham, Kyle R, Hall, Amanda, Dowling, Shawn K, Rodondi, Nicolas, Ellen, Moriah, Kool, Tijn, van Dulmen, Simone A, Kerr, Eve A, Linklater, Stefanie, Levinson, Wendy, Bhatia, R Sacha
• Format: Journal Article
• Language: English
• Published: England BMJ Publishing Group LTD 01.05.2020; BMJ Publishing Group
• Subjects: Accountability; Delivery of Health Care - standards; Guidelines as Topic; Health care; Health Plan Implementation - methods; Hospitals; Humans; Identification; Implementation Science; Initiatives; Intervention; Medical Overuse - prevention & control; Patient-centered care; Patients; Program Development - methods; Program Evaluation - methods; Quality control; Quality improvement; Research and Reporting Methodology; Surgery; Theory; Canada; health services research; healthcare quality improvement; evaluation methodology; patient-centred care; implementation science
• ISSN: 2044-5415; 2044-5423
• DOI: 10.1136/bmjqs-2019-010060

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.