Methods for de-implementation of proven low value care: a national strategy for 40 common hospital treatments

Objectives
Quality of healthcare can be increased and costs reduced by de-implementing ineffective or so called “low value” care. Traditionally programs focus on the de-implementation of one specific low-value care intervention. In this study we focus on the design of a national strategy aimed at overcoming institutional barriers for the de-implementation of 40 low-value interventions.

Methods
We conducted interviews with national experts from different stakeholders (health care providers, medical specialist, government and health insurance) with operational experience in the field of de-implementation. We asked for examples of successful and unsuccessful cases and explored the characteristics of these interventions and the contextual differences. By thematic analyses of the interviews we identified 4 basic principles to support de-implementation of low value care and subsequently, we proposed 4 policy measures based on those principles. Results were presented for feedback to individual experts and to a structured focus group of experts.

Results
Experts mentioned the following factors as barriers for de-implementation: 1) the lack of a learning culture; 2) lack of applicability of comparative effectiveness research (CER) outcomes to daily clinical practice; 3) lack of attention to perceived barriers by patients and operational barriers for professionals and hospitals; and 4) lack of sufficient legislation to enforce de-implementation . A national de-implementation strategy should include (a) audit and feedback on the progress of de-implementation of low-value interventions per hospital in order to create awareness, (b) systematic impact analyses for organisational and perceived barriers for accepting the alternative treatment for low-value care, (c) financial transformation agreements if de-implementation leads to funding problems at hospital level and (d) consensus on acceptable legislation to enforce de-implementation like medical pre-authorisations.

Discussion
Based on experts’ opinion a national strategy on de-implementation of low-value care is both possible and acceptable. Measures should focus on supporting the learning culture (a), lower barriers to acceptance of CER outcomes (b+c) and enforcement if de-implementation still fails (d). These measures are implementable in general and not specific for Dutch health care system. The measures are now applied to seven low-value interventions that are part of a CER study as a test for all 40 interventions.