De-implementation of low-value care

Resources that ought to be used for evidence-based practices are used for practices without a clear benefit. This is called low value care (LVC) and has become a pervasive problem in healthcare in high income countries. Around 30% of care is estimated to be of low value.

Most studies on LVC are within medicine – examinations, lab tests, screening procedures and medications. But of course, whenever there is evidence for a new practice being effective with a need to be implemented - there will probably also be a less effective practice that should be de-implemented. - the process of reducing the use of low value care.

There is a growing interest for de-implementation within the research community of Implementation Science since de-implementation share the same goal of using the limited resources available to the practices with the strongest support. And to do so, sometimes non-evidence-based practices need to be replaced by practices supported by stronger evidence and sometimes, they should simply be removed without being replaced by anything.

In our research we look at several factors. Determinants for the use of and de-implementation of LVC. Strategies used to de-implement LVC. Governance of LVC on all levels of the health care system from national to local. And decision-making processes for the individual physician. We currently have one finalized project and two ongoing projects on de-implementation which all are funded by Forte.

The finalized project – “Old habits die hard – the challenge of de-implementing low-value care”– aimed to explore determinants for the use of low-value care and strategies for de-implementation. We have conducted three scoping reviews on the literature around this, three qualitative studies exploring reasons for using LVC, organizational factors influencing the use of LVC and management strategies for de-implementation of LVC. Finally, we have conducted an intervention study, studying a combination of two strategies to reduce the use of a specific low-value practice.

The first of the ongoing projects, “To do or not to do—balancing governance and professional autonomy to abandon low-value practices”, aims to explore the governance of de-implementation of low-value practices from the perspectives of national and regional governments and senior management at provider organizations. We use qualitative methods to explore governance at the different levels. The results will be used to develop a framework for de-implementation of low-value practices and suggesting practical strategies to improve the governance of de-implementation. 

The second ongoing project, “Beslutsbryderi” zooms into the role of health care professionals and their decision making. We use a factorial survey experiment to examine which factors (including individual preferences, conviction of scientific evidence, patient requests, and health care system) affect their decision to order a practice considered low-value care.