Theory and practical guidance for effective de-implementation of practices across health and care services: a realist synthesis

• DOI: 10.3310/hsdr09020
• Publication Date: 2021-02-03T14:52:26Z
• Authors: Christopher R Burton; Lynne Williams; Tracey Bucknall; Denise Fisher; Beth Hall; Gill Harris; Peter Jones; Matthew Makin; Anne Mcbride; Rachel Meacock; John Parkinson; Jo Rycroft-Malone; Justin Waring
• Keywords: Medicine (General); clinical effectiveness; 610; de-implementation; low-value practice; overuse; 301; 3. Good health; 03 medical and health sciences; R5-920; 0302 clinical medicine; realist synthesis; evidence review; Public aspects of medicine; RA1-1270; health services; concept analysis

Background Health-care systems across the globe are facing increased pressures to balance efficient use of resources and at same time provide high-quality care. There is greater requirement for services be evidence based, but practices that limited clinical effectiveness or cost-effectiveness still occur. Objectives Our objectives included completing a concept analysis de-implementation, surfacing decision-making processes associated with de-implementing through stakeholder engagement, generating an evidence-based realist programme theory ‘what works’ in de-implementation. Design A synthesis was conducted using iterative stakeholder-driven four-stage approach. Phase 1 involved scoping literature conducting interviews develop initial theory. In 2, systematic searches were test this theory, expressed form contingent relationships. These as context–mechanism–outcomes show how particular contexts conditions trigger mechanisms generate outcomes. 3 consisted validation refinement theories interviews. The final phase (i.e. 4) formulated actionable recommendations service leaders. Participants total, 31 stakeholders user/patient representatives, managers, commissioners) took part focus groups telephone Data sources Using keywords identified during work analysis, bibliographic databases May 2018. searched Cochrane Library, Campbell Collaboration, MEDLINE (via EBSCO host ), Cumulative Index Nursing Allied Health Literature National Institute Research Journals Library following via ProQuest platform: Applied Social Sciences Abstracts, Services International Bibliography Sciences, Database Sociological Abstracts. Alerts set up database from 2018 December Online grey snowballing techniques used identify clusters evidence. Results showed de-implementation five main components context over time: (1) what being de-implemented, (2) issues driving (3) action characterising (4) extent planned opportunistic (5) consequences Forty-two papers synthesised six context–mechanism–outcome configurations, which focused on ranging individual behaviours organisational procedures. Current can perpetuate habitual include low-value treatments. Electronic health records designed hide remove treatments choice options, foregrounding best Professionals made aware their strategies increasing attention practice behaviours. Uncertainty about diagnosis patients’ expectations certain opportunities ‘watchful waiting’ active strategy reduce inappropriate investigations prescribing. emotional component clinician–patient relationships limit requiring professional support multimodal educational interventions. Sufficient alignment between policy, public perspectives required success. Limitations Some specific (e.g. de-prescribing) dominate base, may transferability findings. Any inquiry generates findings essentially cumulative should developed further investigation extends range into, example, research empirical studies. Conclusions This review contributes our understanding procedures improved within health-care services, interventions make more accountable prominence whole-system approach Given different dissemination will engage stakeholders, ways, change policy timely manner. Study registration study registered PROSPERO CRD42017081030. Funding project funded by (NIHR) Delivery published full ; Vol. 9, No. 2. See NIHR website information.