Understanding low-value care and associated de-implementation processes: a qualitative study of Choosing Wisely Interventions across Canadian hospitals.

BACKGROUND: Choosing Wisely (CW) is an international movement comprised of campaigns in more than 20 countries to reduce low-value care (LVC). De-implementation, the reduction or removal of a healthcare practice that offers little to no benefit or causes harm, is an emerging field of research. Little is known about the factors which (i) sustain LVC; and (ii) the magnitude of the problem of LVC. In addition, little is known about the processes of de-implementation, and if and how these processes differ from implementation endeavours. The objective of this study was to explicate the myriad factors which impact the processes and outcomes of de-implementation initiatives that are designed to address national Choosing Wisely campaign recommendations. METHODS: Semi-structured interviews were conducted with individuals implementing Choosing Wisely Canada recommendations in healthcare settings in four provinces. The interview guide was developed using concepts from the literature and the Implementation Process Model (IPM) as a framework. All interviews were conducted virtually, recorded, and transcribed verbatim. Data were analysed using thematic analysis. FINDINGS: Seventeen Choosing Wisely team members were interviewed. Participants identified numerous provider factors, most notably habit, which sustain LVC. Contrary to reporting in recent studies, the majority of LVC in the sample was not 'patient facing'; therefore, patients were not a significant driver for the LVC, nor a barrier to reducing it. Participants detailed aspects of the magnitude of the problems of LVC, providing insight into the complexities and nuances of harm, resources and prevalence. Harm from potential or common infections, reactions, or overtreatment was viewed as the most significant types of harm. Unique factors influencing the processes of de-implementation reported were: influence of Choosing Wisely campaigns, availability of data, lack of targets and hard-coded interventions. CONCLUSIONS: This study explicates factors ranging from those which impact the maintenance of LVC to factors that impact the success of de-implementation interventions intended to reduce them. The findings draw attention to the significance of unintentional factors, highlight the importance of understanding the impact of harm and resources to reduce LVC and illuminate the overstated impact of patients in de-implementation literature. These findings illustrate the complexities of de-implementation.

Reframing Resource Stewardship and Sustainability as Professionalism: What Can Efforts for a Net-Zero Health System Learn from Choosing Wisely Campaigns?

Miller and Xie (2020) issue a compelling and wide-ranging call to action for how healthcare systems, leaders and decision makers can and should mobilize to address the climate crisis. Issues of sustainability and the climate crisis are complex, wicked problems with no simple solutions. Sustainability considerations and the imperative to use healthcare system resources wisely are a motivator of the Choosing Wisely Canada campaign. These considerations are increasingly urgent in the context of fiscal and resource deficits due to the COVID-19 pandemic. The experience of Choosing Wisely campaigns can offer potential strategies for driving increased awareness and action from healthcare stakeholders on the climate crisis. This commentary explores some of the factors that have contributed to the spread of Choosing Wisely campaigns and the levers that have fostered campaign uptake. It will also consider the challenges faced by, and lessons learned, from Choosing Wisely campaigns, and how these could inform healthcare systems and individual clinicians in increasing awareness and taking leadership on the climate crisis.