Background
Phase of de-adoption | Operational definition |
---|---|
Identify low-value clinical practices | Ascertain which clinical practices are of low value |
Facilitate the de-adoption process | Reduce the use of low-value clinical practices |
Evaluate de-adoption outcomes | Evaluate the outcomes of a strategy of de-adoption |
Sustain de-adoption | Prevent resurgence in use of low-value practices after their initial de-adoption |
Methods
Eligibility criteria
Search strategy and data sources
Citation selection
Data extraction and synthesis
Results
Description of the included citations
Characteristic | Number (%) of 109 citations |
---|---|
Year of publication | |
1990–1999 | 3 (3) |
2000–2009 | 42 (38) |
2010–current | 64 (59) |
Country of origina
| |
North America | 65 (60) |
Europe | 30 (28) |
Australasia | 22 (20) |
Type of article | |
Original research | 71 (65) |
Quasi-experimentalc
| 30 (28) |
Cohort studyb
| 15 (14) |
Mixed methods | 8 (7) |
Qualitative | 4 (4) |
Predictive modeling | 3 (3) |
Knowledge synthesis | 3 (3) |
Consensus method | 3 (3) |
Randomized clinical trial | 1 (1) |
Otherd
| 6 (6) |
Non-original research | 38 (35) |
Editorial, letter to the editor, news item, other | 21 (19) |
Narrative review | 16 (15) |
Guideline | 1 (1) |
Focus of article | |
Identify low-value practices | 51 (47) |
Facilitate the de-adoption process | 44 (40) |
Evaluate de-adoption outcomes | 54 (50) |
Sustain de-adoption | 2 (2) |
Type of interventione
| |
Therapeutic | 68 (62) |
Drug | 34 (31) |
Device or surgical procedure | 16 (15) |
Drugs and devices/procedures | 16 (15) |
Other | 3 (3) |
Diagnostic | 27 (30) |
Laboratory | 7 (8) |
Physiologic measurement | 4 (4) |
Diagnostic imaging | 3 (3) |
Screening program | 1 (1) |
Diagnostic tests not otherwise specified | 12 (13) |
Evidence to promote de-adoptionf
| |
Randomized clinical trial | 45 (41) |
Knowledge synthesis | 14 (13) |
Clinical practice guideline | 6 (5) |
Cohort study | 4 (4) |
Quasi-experimentalc
| 2 (2) |
Expert consensus | 2 (2) |
Reasons for de-adoptiong
| |
Harm | 80 (73) |
Lack of efficacy | 69 (63) |
Not cost-effective | 37 (34) |
De-adoption terminology
Terma
| Number (%) of 109 citationsb
| Number (%) of citations with term listed in title or abstract | Relationship to the proposed conceptual framework | References |
---|---|---|---|---|
Disinvest* | 42 (39) | 34 (31) | Facilitate de-adoption | |
Sustain de-adoption | ||||
Decrease use | 26 (24) | 13 (12) | Facilitate de-adoption | |
Evaluate de-adoption outcomes | ||||
Discontinu* | 17 (16) | 7 (6) | Facilitate de-adoption | |
Evaluate de-adoption outcomes | ||||
Abandon* | 17 (16) | 4 (4) | Sustain de-adoption | |
Reassess* | 15 (14) | 8 (7) | Identify low-value practices | |
Obsole* | 13 (12) | 6 (6) | Identify low-value practices | |
Medical reversal | 12 (11) | 7 (6) | Identify low-value practices | |
Contradict | 11 (10) | 3 (3) | Identify low-value practices | |
Re-invest | 9 (8) | 0 (0) | Sustain de-adoption | |
Withdraw* | 8 (7) | 8 (7) | Facilitate de-adoption | |
Sustain de-adoption | ||||
Reduc* | 8 (7) | 1 (1) | Evaluate de-adoption outcomes | |
Decline in use | 7 (6) | 0 (0) | Evaluate de-adoption outcomes | |
Health technology reassessment | 5 (5) | 4 (4) | Identify low-value practices | |
Change in use | 4 (4) | 2 (2) | Evaluate de-adoption outcome | |
De-implement* | 4 (4) | 2 (2) | Facilitate de-adoption | |
De-list | 4 (4) | 0 (0) | Facilitate de-adoption | |
Sustain de-adoption | ||||
Low value practice/intervention | 4 (4) | 2 (2) | Identify low-value practices | |
Change in practice | 3 (3) | 1 (1) | Evaluate de-adoption outcome | |
De-adopt* | 3 (3) | 2 (2) | Facilitate de-adoption | |
Evaluate de-adoption outcomes | ||||
De-commission | 3 (3) | 1 (1) | Facilitate de-adoption | |
Sustain de-adoption | ||||
Do not do | 3 (3) | 1 (1) | Facilitate de-adoption | |
Reallocation | 3 (3) | 0 (0) | Sustain de-adoption | |
Remov* | 3 (3) | 0 (0) | Facilitate de-adoption | |
Sustain de-adoption | ||||
Replace | 3 (3) | 0 (0) | Facilitate de-adoption | |
Sustain de-adoption | ||||
Refute | 3 (3) | 1 (1) | Identify low-value practices | |
Over use | 3 (3) | 0 (0) | Identify low-value practices | |
Stop* | 3 (3) | 1 (1) | Facilitate de-adoption | |
Inappropriate use | 2 (2) | 1 (1) | Identify low-value practices | |
Relinquish* | 2 (2) | 1 (1) | Facilitate de-adoption | |
Sustain de-adoption | ||||
Ineffective | 2 (2) | 1 (1) | Identify low-value practices | |
Misuse | 1 (1) | 0 (0) | Identify low-value practices | [127] |
Re-appraisal | 1 (1) | 0 (0) | Identify low-value practices | [79] |
Re-prioritization | 1 (1) | 0 (0) | Sustain de-adoption | [79] |
Substitutional re-investment | 1 (1) | 0 (0) | Facilitate de-adoption | [79] |
Sustain de-adoption | ||||
Evidence-based reassessment | 1 (1) | 0 (0) | Identify low-value practices | [79] |
Clinical redesign | 1 (1) | 0 (0) | Facilitate de-adoption | [79] |
Disadoption | 1 (1) | 0 (0) | Facilitate de-adoption | [101] |
Defunding | 1 (1) | 0 (0) | Facilitate de-adoption | [57] |
Sustain de-adoption | ||||
Resource release | 1 (1) | 0 (0) | Facilitate de-adoption | [57] |
Sustain de-adoption | ||||
Withdrawing from a service and redeploying resources | 1 (1) | 0 (0) | Facilitate de-adoption | [57] |
Sustain de-adoption | ||||
Redeploy | 1 (1) | 1 (1) | Facilitate de-adoption | [68] |
Sustain de-adoption | ||||
Reversal | 1 (1) | 0 (0) | Identify low-value practices | [96] |
Facilitate de-adoption | ||||
Sustain de-adoption | ||||
Drop in use | 1 (1) | 0 (0) | Facilitate de-adoption | [31] |
Evaluate de-adoption |
Barriers and facilitators to de-adoption
Mapping citations to the de-adoption conceptual framework
Citation | Type of citation | Relationship to conceptual framework (Table 1) | Description | Documented clinical application |
---|---|---|---|---|
Elshaug et al. 2009 [109] | Discussion paper prepared by Canadian Agency for Drugs and Technologies in Health Health Technology Strategy Policy Forum | Identify low-value practices | Criteria for identifying existing, potentially non-cost-effective practices as candidates for assessment | No |
Criteria to inform the prioritization of candidates for detailed review after identification | ||||
Facilitate the de-adoption process | Funding approaches to facilitating reduction in non-cost-effective practices | No | ||
Joshi et al. 2009 [80] | Narrative review | Identify low-value practices | HTR approach to identifying candidate technologies | No |
Ibargoyen-Roteta et al. 2010 [55] | Guideline | Identify of low-value practices | GuNFT: Hospital and patient-level criteria for not funding technologies | No |
Facilitate the de-adoption process | Barriers and mechanisms to remove funding from existing technologies | No | ||
Mortimer 2010 [68] | Narrative review | Facilitate the de-adoption process | Proposed re-orientation of traditional PBMA model to target strategies of disinvestment | Not with the re-oriented PBMA model as outlined by the authors |
Donaldson et al. 2010 [72] | Narrative review | Facilitate the de-adoption process | Describes the use of PBMA to promote rational disinvestment | Not according to the model outlined by the authors |
Gerdvilaite and Nachtnebel 2011 [57] | Systematic review | Identify of low-value practices | No | |
Overlapping criteria include new evidence, cost effectiveness, safety, and available alternatives | ||||
Facilitate the de-adoption process | As described above for Ibargoyen-Roteta et al. [55] | No | ||
Levin 2011 [20] | Conference presentation | Identify of low-value practices | Ontario’s Evidence-based Analyses to Manage Technology Adoption and Obsolescence: Mega-analysis Evidence Based Analyses of technologies around disease conditions; prioritized by effectiveness and cost-effectiveness; criteria for identifying practices unclear | Yes |
Facilitate the de-adoption process | Mechanism for facilitating de-adoption appears to be based on funding effective technologies, and not funding ineffective technologies | Yes | ||
Leggett et al. 2012 [58] | Systematic review | Identify of low-value practices; Facilitate the de-adoption process | 1.GuNFT as outlined above | No |
2.5-steps for HTR should include: identification, prioritization, evaluation, implementation, and monitoring | ||||
Watt et al. 2012 [46] | Mixed methods | Facilitate the de-adoption process | Two technologies (assisted reproductive technology and vitamin B12/folate pathology tests) used as case studies to test a three-level model to facilitate de-adoption including: | No (study ongoing) |
1. Evidence reports | ||||
2. Stakeholder engagement | ||||
3. Policy deliberation and analysis; Process evaluation | ||||
Henshall and Schuller 2012 [52] | Qualitative | Identify of low-value practices | Identification and prioritization approaches include clinical stakeholder involvement, monitoring new evidence, use of data to identify practices with high variability and/or cost, inclusion of HTR within life-cycle of any technology | No |
Polisena et al. 2013 [19] | Systematic review | Facilitate the de-adoption process | Three different models to facilitate disinvestment decisions: | Yes; varied by included study |
1. Health technology assessment framework | ||||
2. Program budgeting and marginal analysis | ||||
3. Accountability for reasonableness and quality improvement theory |
Citation | Stakeholder engagement | Single clinical area of focus | Methodology | Results |
---|---|---|---|---|
Ioannidis 2005 [24] | No | No | Broad literature search (1990–2003) for highly cited clinical research studies published in three major clinical journalsa or medical specialty journals with an impact factor >7.0 | 7 of 45 (16 %) highly cited studies claiming effectiveness eventually contradicted by replication research |
Supplemental, tailored searches to determine if each highly cited study had been replicated | 7 other replication studies (16 %) found effect size not as large as in original study | |||
Comparison of direction of results between replicated and original highly cited study | ||||
Prasad et al. 2011 [5] | No | No | Review of all “original articles” published in New England Journal of Medicine in 2009 | 35 of 124 (28 %) articles examined an existing medical practice |
Articles classified according to whether the practice examined was new or already in place, and whether the results were positive or negative for the primary endpoint | 16 of 35 (46 %) articles examining an existing practice demonstrated medical reversalb
| |||
Elshaug et al. 2012 [8] | Comprehensive Management Framework for Australia’s Medicare Benefits Schedule | No | Environmental scanning approach triangulating data from broad PubMed search (2000–2010), targeted searches within select databases (e.g., Cochrane library), and opportunistic sampling among clinical and non-clinical stakeholders | 156 potentially ineffective or unsafe practices identified from 5,209 screened articles |
Excluded pharmaceuticals | ||||
Choosing Wisely 2012 [21] | Yes | Yes, specialty specific recommendations | Varied by specialty society but generally included one or more of literature search, expert opinion, and/or a modified Delphi process | 67 specialty specific Top 5 ‘do not do’ lists |
Garner et al. 2013 [70] | NICE | No | Present results from the first 6 months of the Cochrane Quality and Productivity project to identify low-value practices | 28 of 65 (43 %) reviews published over a 6-month period identified potentially low-value practices |
Routine scanning of “implications for practice” section in new or updated Cochrane reviews to identify those wherein the author concluded an intervention is ineffective/harmful or should be confined to use within a research context | Most reviews cited a lack of randomized evidence of effectiveness, rather than robust evidence of lack of effectiveness | |||
Each review is examined to ensure it meets Cochrane Quality and Productivity criteria (potential impact on quality, safety, patient/provider experience, and potential for cash-releasing savings) for recommendation as a potential “disinvestment” candidate | To date the NICE Health Technology Appraisal Program has generated 1,347 ‘do not do’ recommendations [130] | |||
Hollingworth et al. 2013 [23] | No | Yes, interventional procedures | Used UK Hospital Episode Statistics to identify inpatient interventional procedures with high variation in rates of use between PCTs in England | Substantial inter-procedure, inter-PCT variation in procedure rates |
Procedures with high variation not listedc
| ||||
Prasad et al. 2013 [7] | No | No | Review of all original research articles published in New England Journal of Medicine from 2001 to 2010 | 363 of 1,344 (27 %) articles re-examined an established practice |
Articles classified according to whether the practice examined was new or already in place, and whether the results were positive or negative for the primary endpoint | 146 of 363 (40 %) articles re-examining an existing practice demonstrated evidence of reversal | |||
Articles further classified as replacement, back to the drawing board, reversal, or reaffirmation
d
| ||||
Choosing Wisely Canada 2014 [22] | Yes | Yes, specialty specific recommendations | Varied by specialty society but generally included one or more of literature search, expert opinion, and/or a modified Delphi process | 61 recommendations across 18 medical and surgical specialties |
Citation | Study design | Target condition | Low-value practice | Evidence guiding de-adoption | Reason practice considered low-value | Reduction in use of low-value practice | Other notable results |
---|---|---|---|---|---|---|---|
Active change intervention facilitated de-adoption
b
| |||||||
Ross-Degnan et al. 1993 [29] | Interrupted time series | Arthritides | NSAIDs, Zomepirac | Case series | Harmful | Yes | Increased prescription of other NSAIDs |
Williams et al. 2006 [30] | Interrupted time series | Arthritides | COX-2 inhibitors | RCT | Harmful | Yes | Safety concerns for rofecoxib interpreted as class effect |
Thiebaud et al. 2006 [31] | Cohort study | Arthritides | COX-2 inhibitors | RCT | Harmful | Yes | Greater decrease in COX-2 inhibitor use among patients with greater number of cardiovascular comorbidities |
Barozzi and Tett 2007 [32] | Interrupted time series | Arthritides | COX-2 inhibitors | RCT | Harmful | Yes | Safety concerns for rofecoxib interpreted as class effect; prescription of non-selective NSAIDs increased |
Sun et al. 2007 [33] | Interrupted time series | Arthritides | COX-2 inhibitors | RCT | Harmful | Yes | Significant increases in non-selective NSAID use after withdrawal of rofecoxib and valdecoxib |
Setakis et al. 2008 [34] | Before-and-after | Arthritides | COX-2 inhibitors | RCT | Harmful | Yes | After withdrawal of rofecoxib, remaining use of COX-2 inhibitors did not concentrate in patients with high gastrointestinal risk and low cardiovascular risk |
Sukel et al. 2008 [35] | Before-and-after | Arthritides | COX-2 inhibitors | RCT | Harmful | Yes | Safety concerns for rofecoxib interpreted as class effect |
Hsiao et al. 2009 [36] | Cohort | Arthritides | COX-2 inhibitors | RCT | Harmful | Yes | Safety concerns for rofecoxib interpreted as class effect |
Stafford and Radley 2003 [37] | Interrupted time series | Obesity | Fenfluramine and dexfenfluramine | Case–control study | Harmful | Yes | No change in practice after reports of adverse events. Market withdrawal of drug required to change practice |
Krol et al. 2004 [27] | Cluster RCT | PPI use | PPIs in those without indications for their continued use | Clinical practice guideline | Not reported | Yes | No recrudescence of symptomatology associated with original PPI prescription after its discontinuation |
Roumie et al. 2004 [25] | Interrupted time series | Post-menopausal women | HRT | RCT | Harmful | Yes | Greater rate of discontinuation of HRT after tailored de-adoption intervention compared to media release of results of WHI study |
Kulawik et al. 2009 [28] | Before-and-after | End-stage renal disease | Use of tunnelled hemodialysis catheters in patients with end-stage renal disease | Cohort, quasi-experimental, and clinical practice guideline | Harmful, not cost effective | Yes | Involvement of medical leader improved rate of reduction in catheter use |
Sindby et al. 2011 [26] | Before-and-after | Coronary artery bypass surgery | Blood transfusions | Not reported | Not reported | Yes | Not reported (conference abstract) |
No intervention used to facilitate de-adoption
c
| |||||||
Austin et al. 2003 [99] | Interrupted time series | Post menopausal women | HRT | RCT | Harmful | Yes | Unable to determine if decline in HRT use patient or physician-initiated |
Lawton et al. 2003 [124] | Survey | Post menopausal women | HRT | RCT | Harmful | Yes | Factors associated with stopping HRT included older age, use of combined HRT, longer duration of HRT |
Haas et al. 2004 [118] | Interrupted time series | Post menopausal women | HRT | RCT | Harmful | Yes | Greater decrease in HRT use after WHI study compared to Heart and Estrogen/progestin Replacement Study |
Hersh et al. 2004 [103] | Interrupted time series | Post menopausal women | HRT | RCT | Harmful | Yes | Response to publication of WHI study was rapid |
Majumdar et al. 2004 [98] | Interrupted time series | Post menopausal women | HRT | RCT | Harmful | Yes | Substantial decline in promotional spending for HRT after publication of WHI study |
Huang et al. 2007 [122] | Cohort | Post menopausal women | HRT | RCT | Harmful | Yes | Factors associated with reduction in use of HRT included higher patient education, and care at an academic institution |
Majumdar et al. 2001 [97] | Before-and-after | Acute coronary syndrome | Calcium channel blockers Lidocaine | Case–control study; Systematic review | Harmful | Yes | No difference in calcium channel blocker discontinuation according to physician specialty |
Brunt et al. 2003 [120] | Interrupted time series | Hypertension | Short acting calcium channel blockers | Case–control study | Harmful | Yes | Proportionate increase in other anti-hypertensive medication paralleled discontinuation of calcium channel blockers |
Stafford et al. 2004 [96] | Interrupted time series | Hypertension | Alpha-blockers | RCT | Harmful | Yes | Substantial decrease in office promotion expenditures for alpha-blockers following publication of ALLHAT trial |
Xie et al. 2005 [95] | Interrupted time series | Hypertension | Alpha-blockers | RCT | Harmful | Yes | Decrease in alpha-blockers associated with increase in other anti-hypertensive medications |
Hauptman et al. 2006 [18] | Interrupted time series | Congestive heart failure | Nesiritide | Systematic review | Harmful | Yes | Decrease in nesiritide use associated with increased use of inotropes |
Atwater et al. 2009 [90] | Before-and-after | Coronary artery disease | PCI | RCT | Lack of efficacy | Yes | Decrease in PCI and increase in medical therapy following COURAGE trial |
Bonakdar tehrani and Howard 2011 [84] | Before-and-after | Coronary artery disease | PCI | RCT | Lack of efficacy | Yes | PCI use decreased after COURAGE trial, however considerable number of patients with stable angina continued to receive PCI |
Deyell et al. 2011 [89] | Interrupted time series | Coronary artery disease | PCI | RCT | Lack of efficacy | No | No change in PCI after OAT trial or guideline revisions |
Ahmed et al. 2011 [93] | Interrupted time series | Coronary artery disease | PCI | RCT | Lack of efficacy | Yes | Decrease in PCI use was sustained up to 2 years after publication of COURAGE trial |
Wiener and Welch 2007 [91] | Interrupted time series | Critical illness | PAC | RCT; Systematic review | Lack of efficacy | Yes | PAC use began to decline after publication of large observational study (before publication of any RCTs) |
Koo et al. 2011 [87] | Interrupted time series | Critical illness | PAC | RCT; Systematic review | Lack of efficacy | Yes | Examined patient, physician, and unit-level predictors of PAC use |
Gershengorn and Wunsch 2013 [128] | Cohort | Critical illness | PAC | RCT; Systematic review | Lack of efficacy | Yes | Surgical patients continue to have high likelihood of PAC use |
Murphy et al. 2013 [92] | Cohort | Critical illness | Blood transfusions | RCT | Harmful | Yes (higher volume hospitals only) | Likelihood of receiving blood transfusion after publication of TRICC trial dependent on annualized intensive care unit patient volume |
Duffy and Farley 1992 [105] | Cohort | Chronic obstructive pulmonary disease | IPPB | RCT | Lack of efficacy | Yes | Hospital-level traits and models of funding technologies were associated with discontinuing IPPB |
Smalley et al. 2000 [121] | Before-and-after | Gastric motility disorders | Cisapride | Case series; Warning letter from Food and Drug Administration | Harmful | No | Cisapride use not effected by black-box US Food and Drug Administration warning regarding harmful effects |
Howard et al. 2011 [101] | Interrupted time series | Breast cancer | High dose chemotherapy/Hematopoietic cell transplants | RCT | Lack of efficacy and harmful | Yes | No association between hospital teaching status and participation in clinical trials, and decline in use of the low-value practice |
Chamberlain et al. 2013 [56] | Interrupted time series | (1) Pregnant women with hepatitis | (1) Caesarean section | Clinical practice guideline (NICE ‘do not do’ recommendation) | Lack of efficacy and harmful | No | “Do not do” recommendation reminders had no association with changes in clinical practice |
(2) Infertile men and women | (2) Fertility procedures | ||||||
Kowalczyk et al. 2012 [82] | Cohort | Prostate cancer | RRP | Cohort study | Not reported | Yes | Decrease in RRP was associated with an increase in RRP-related complications |
Luetmer and Kallmes 2011 [88] | Before-and-after | Vertebral fracture | Vertebroplasty | RCT | Lack of efficacy | Yes | Referrals for vertebroplasty decreased, however proportion of referrals undergoing the procedure increased |
Ehrenstein et al. 2013 [94] | Interrupted time series | Diabetes mellitus | Rosiglitazone | Systematic review Cohort study | Harmful | Yes | No significant change in markers of glycemic control after discontinuation of rosiglitazone |