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

Gangathimmaiah, Vinay, Drever, Natalie, Evans, Rebecca, Moodley, Nishila, Sen Gupta, Tarun, Cardona, Magnolia, and Carlisle, Karen (2023) What works for and what hinders deimplementation of low-value care in emergency medicine practice? A scoping review. BMJ Open, 13 (11). e072762.

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Objectives: Low-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.

Design: A mixed-methods scoping review was conducted using the Arksey and O'Malley framework.

Data Sources: Medline, CINAHL, Embase, EMCare, Scopus and grey literature were searched from inception to 5 December 2022.

Eligibility Criteria: Primary 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 Synthesis: Study 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.

Results: The 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.

Conclusion: High-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.

Item ID: 81232
Item Type: Article (Research - C1)
ISSN: 2044-6055
Copyright Information: © Author(s) (or their employer(s)) 2023. This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
Date Deposited: 05 Mar 2024 01:06
FoR Codes: 32 BIOMEDICAL AND CLINICAL SCIENCES > 3202 Clinical sciences > 320207 Emergency medicine @ 70%
42 HEALTH SCIENCES > 4206 Public health > 420699 Public health not elsewhere classified @ 30%
SEO Codes: 20 HEALTH > 2002 Evaluation of health and support services > 200206 Health system performance (incl. effectiveness of programs) @ 30%
20 HEALTH > 2003 Provision of health and support services > 200311 Urgent and critical care, and emergency medicine @ 70%
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