Evidence That Drives Real Change

Authors: Hanna Augustsson Öfverström, Sara Ingvarsson, Emma Hedberg Rundgren, Marta Roczniewska, Henna Hasson, Per Nilsen, Ulrica von Thiele Schwarz.

Year: 2026

Abstract:
Background: Low-value care (LVC) remains a persistent problem in primary healthcare. While various implementation strategies have been proposed and tested for deimplementation, there is limited knowledge about whether there are strategies uniquely suited to deimplementation. Furthermore, there is limited knowledge about system-level responsibilities for deimplementation. Given that implementation strategies are recommended to be tailored to the specific contextual factors surrounding LVC practices, involving primary care physicians in identifying contextually appropriate strategies holds promise. This study aimed to explore the strategies that primary care physicians suggest could facilitate the deimplementation of LVC and map them to the system levels responsible for initiating and deploying these strategies.

Methods: This qualitative study was based on responses to an open-ended survey question asking physicians to suggest strategies that could facilitate the deimplementation of LVC practices within primary healthcare in Sweden. A national sample of 441 primary care physicians responded. Responses were analyzed via deductive content analysis categorized by the Expert Recommendations for Implementing Change (ERIC) compilation. Responses that could not be categorized via ERIC were analyzed inductively. The identified strategies were then mapped to the system levels (individual, group, leader, organization and overarching system) responsible for deploying these strategies.

Results: Strategies were identified across all nine original ERIC domains, representing 39 (53%) of the original ERIC strategies, and later additions for deimplementation. Additionally, a set of strategies categorized under a new domain, develop better evidence, was identified. Most strategies were suitable for deployment at the organizational (31 strategies) and overarching (31 strategies) levels. Sixteen strategies were best suited for the group level, thirteen for the leadership level, and two for the individual level.

Conclusion: Primary care physicians proposed strategies across all nine ERIC domains, with additional strategies beyond those previously described, including develop better evidence. From the physicians’ perspective, deimplementation cannot rely solely on individuals but requires coordinated action across the organizational and system levels. Broader structural, policy, and cultural changes would support physicians and ensure that responsibility for deimplementation is shared across the healthcare system.

Authors: Aleksi Raudasoja, Sameer Parpia, Jussi M J Mustonen, et al.

Year: 2025

Abstract: Objective: To evaluate the effectiveness of various de-implementation interventions in primary care, targeting care (treatments or tests) that provides no or limited value for patients (low value care).

Design: Systematic review and meta-analysis.

Data sources: Medline and Scopus databases, from inception to 10 July 2024.

Eligibility criteria for selecting studies: Randomised trials comparing de-implementation interventions with placebo or sham intervention, no intervention, or other de-implementation intervention strategies in primary care. Eligible trials provided information on the use of low value care, total volume of care, appropriate care, and health outcomes.

Data extraction and synthesis: Titles, abstracts, and full texts were screened, data were extracted, and risk of bias was assessed independently and in duplicate. Random effects meta-analyses were conducted, and the certainty of evidence was assessed with the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach.

Results: 13 008 abstracts were screened and 140 were eligible for inclusion in the study. Median follow-up was 287 days (interquartile range 180-365). In 75 (54%) trials the aim was to reduce the use of antibiotics, in 42 (30%) to reduce other drug treatments, in 17 (12%) to reduce imaging, and in 15 (11%) to reduce laboratory testing. The certainty of the evidence was moderate that provider education combined with audit and feedback reduced the use of targeted low value care (odds ratio 0.73, 95% confidence interval (95% CI) 0.63 to 0.84). Provider education (0.86, 95% CI 0.72 to 1.03), audit and feedback (0.82, 0.67 to 1.00), and patient education (0.70, 0.30 to 1.66), and a combination of these strategies (point estimates for odds ratios ranging from 0.57 to 0.64) may reduce the use of targeted low value care (low certainty of evidence for all).

Conclusions: The results suggested with moderate certainty of evidence that provider education combined with audit and feedback reduced the use of targeted low value care. Individual strategies may slightly reduce the use of targeted low value care, but achieving a meaningful impact on low value care may require the use of multiple strategies. The results may be useful for patients, clinicians, policy makers, and guideline developers when deciding on future de-implementation strategies and research priorities.

Authors: Bobbio, M., Chiarlo, M., Arcadi, P. et al.

Year: 2025

Abstract:
In the last decade literature focused on a “less is more” approach has been primarily represented by clinical cases describing the excesses of an aggressive, redundant, non-personalized, and non-respectful medicine. Most of these articles focus on a “more is worse” approach and centre around the downstream negative consequences of medical overuse. Having identified a gap in the literature on the experience and practice of less, rather than the harms of excess, we carried out an exploratory qualitative study into how a “less is more” approach works in practice. A hermeneutic phenomenological approach was adopted to allow us to examine the realm of lived experience as a valid data source and as a path from which to understand a “less is more” approach “from the bedside.” A Phenomenology of Practice was chosen as a more specific frame for this research because of its added focus on action and practical application in professional settings. Seventy stories written by physicians, patients, nurses, caregivers, and other health professionals have been received and analysed. These stories were gathered as part of a project called “Slow Stories” which aimed to collect clinical cases that have been positively resolved by adopting a “less is more” approach to patient care. After having conducted an in-depth analysis, separately and as a group, the researchers identified five key phenomenological themes; Time to relate is time to heal; Doing more does not mean doing better; Settings for a slow medicine; Slow care at the end of life; and Personalized vs. standardized treatment. Each of these themes offers insights into how a “less is more” approach can be used in practice and illustrates how a “less is more” strategy can play a significant role in positively resolving certain clinical cases.

Authors: Raudasoja A, Tikkinen KAO, Bellini B, Ben-Sheleg E, Ellen ME, Francesconi P, Hussien M, Kaji Y, Karlafti E, Koizumi S, Ouahrani E, Paier-Abuzahra M, Savopoulos C, Spary-Kainz U, Komulainen J, Sipilä R.

Year: 2024

Abstract:
Background: Healthcare costs are rising worldwide. At the same time, a considerable proportion of care does not benefit or may even be harmful to patients. We aimed to explore attitudes towards low-value care and identify the most important barriers to the de-implementation of low-value care use in primary care in high-income countries.

Methods: Between May and June 2022, we email surveyed primary care physicians in six high-income countries (Austria, Finland, Greece, Italy, Japan, and Sweden). Physician respondents were eligible if they had worked in primary care during the previous 24 months. The survey included four sections with categorized questions on (1) background information, (2) familiarity with Choosing Wisely recommendations, (3) attitudes towards overdiagnosis and overtreatment, and (4) barriers to de-implementation, as well as a section with open-ended questions on interventions and possible facilitators for de-implementation. We used descriptive statistics to present the results.

Results: Of the 16,935 primary care physicians, 1,731 answered (response rate 10.2%), 1,505 had worked in primary care practice in the last 24 months and were included in the analysis. Of the respondents, 53% had read Choosing Wisely recommendations. Of the respondents, 52% perceived overdiagnosis and 50% overtreatment as at least a problem to some extent in their own practice. Corresponding figures were 85% and 81% when they were asked regarding their country's healthcare. Respondents considered patient expectations (85% answered either moderate or major importance), patient's requests for treatments and tests (83%), fear of medical error (81%), workload/lack of time (81%), and fear of underdiagnosis or undertreatment (79%) as the most important barriers for de-implementation. Attitudes and perceptions of barriers differed significantly between countries.

Conclusions: More than 80% of primary care physicians consider overtreatment and overdiagnosis as a problem in their country's healthcare but fewer (around 50%) in their own practice. Lack of time, fear of error, and patient pressures are common barriers to de-implementation in high-income countries and should be acknowledged when planning future healthcare. Due to the wide variety of barriers to de-implementation and differences in their importance in different contexts, understanding local barriers is crucial when planning de-implementation strategies.

Authors: Pauline Heus; Simone A. van Dulmen; Jan-Willem Weenink; Christiana A. Naaktgeboren; Toshihiko Takada; Eva W. Verkerk; Isabelle Kamm; Maarten J. van der Laan; Lotty Hooft; Rudolf B. Kool

Year: 2023

Abstract:
Background: Low-value care is healthcare leading to no or little clinical benefit for the patient. The best (combinations of) interventions to reduce low-value care are unclear.

Purpose: To provide an overview of randomized controlled trials (RCTs) evaluating deimplementation strategies, to quantify the effectiveness and describe different combinations of strategies.

Methods: Analysis of 121 RCTs (1990–2019) evaluating a strategy to reduce low-value care, identified by a systematic review. Deimplementation strategies were described and associations between strategy characteristics and effectiveness explored.

Results: Of 109 trials comparing deimplementation to usual care, 75 (69%) reported a significant reduction of low-value healthcare practices. Seventy-three trials included in a quantitative analysis showed a median relative reduction of 17% (IQR 7%–42%). The effectiveness of deimplementation strategies was not associated with the number and types of interventions applied.

Conclusions and Implications: Most deimplementation strategies achieved a considerable reduction of low-value care. We found no signs that a particular type or number of interventions works best for deimplementation. Future deimplementation studies should map relevant contextual factors, such as the workplace culture or economic factors. Interventions should be tailored to these factors and provide details regarding sustainability of the effect.

Authors: Sara Ingvarsson, Henna Hasson, Ulrica von Thiele Schwarz, Per Nilsen, Byron J Powell, Clara Lindberg, Hanna Augustsson.

Year: 2022

Abstract:
Background: The use of low-value care (LVC) is a persistent problem that calls for knowledge about strategies for de-implementation. However, studies are dispersed across many clinical fields, and there is no overview of strategies that can be used to support the de-implementation of LVC. The extent to which strategies used for implementation are also used in de-implementing LVC is unknown. The aim of this scoping review is to (1) identify strategies for the de-implementation of LVC described in the scientific literature and (2) compare de-implementation strategies to implementation strategies as specified in the Expert Recommendation for Implementing Change (ERIC) and strategies added by Perry et al.

METHOD: A scoping review was conducted according to recommendations outlined by Arksey and O'Malley. Four scientific databases were searched, relevant articles were snowball searched, and the journal Implementation Science was searched manually for peer-reviewed journal articles in English. Articles were included if they were empirical studies of strategies designed to reduce the use of LVC. Two reviewers conducted all abstract and full-text reviews, and conflicting decisions were discussed until consensus was reached. Data were charted using a piloted data-charting form. The strategies were first coded inductively and then mapped onto the ERIC compilation of implementation strategies.

Results: The scoping review identified a total of 71 unique de-implementation strategies described in the literature. Of these, 62 strategies could be mapped onto ERIC strategies, and four strategies onto one added category. Half (50%) of the 73 ERIC implementation strategies were used for de-implementation purposes. Five identified de-implementation strategies could not be mapped onto any of the existing strategies in ERIC.

Conclusions: Similar strategies are used for de-implementation and implementation. However, only a half of the implementation strategies included in the ERIC compilation were represented in the de-implementation studies, which may imply that some strategies are being underused or that they are not applicable for de-implementation purposes. The strategies assess and redesign workflow (a strategy previously suggested to be added to ERIC), accountability tool, and communication tool (unique new strategies for de-implementation) could complement the existing ERIC compilation when used for de-implementation purposes.

Authors: Eva W Verkerk, Simone A Van Dulmen, Karen Born, Reshma Gupta, Gert P Westert, Rudolf B Kool

Year: 2021

Abstract:
Background: Around the world, policies and interventions are used to encourage clinicians to reduce low-value care. In order to facilitate this, we need a better understanding of the factors that lead to low-value care. We aimed to identify the key factors affecting low-value care on a national level. In addition, we highlight differences and similarities in three countries.

Methods: We performed 18 semi-structured interviews with experts on low-value care from three countries that are actively reducing low-value care: the United States, Canada, and the Netherlands. We interviewed 5 experts from Canada, 6 from the United States, and 7 from the Netherlands. Eight were organizational leaders or policy-makers, 6 as low-value care researchers or project leaders, and 4 were both. The transcribed interviews were analyzed using inductive thematic analysis.

Results: The key factors that promote low-value care are the payment system, the pharmaceutical and medical device industry, fear of malpractice litigation, biased evidence and knowledge, medical education, and a 'more is better' culture. These factors are seen as the most important in the United States, Canada and the Netherlands, although there are several differences between these countries in their payment structure, and industry and malpractice policy.

Conclusion: Policy-makers and researchers that aim to reduce low-value care have experienced that clinicians face a mix of interdependent factors regarding the healthcare system and culture that lead them to provide low-value care. Better awareness and understanding of these factors can help policy-makers to facilitate clinicians and medical centers to deliver high-value care.