Ethical considerations in the de-adoption of ineffective or harmful aspects of healthcare

Sticking with Programs That Do Not Work: The Role of Escalation of Commitment in Schools

Schools are the most common site to implement evidence-based prevention programs and practices (EBPs) to improve behavioral and mental health outcomes among children and adolescents. Research has highlighted the critical role of school administrators in the adoption, implementation, and evaluation of such EBPs, focusing on the factors they should consider during the adoption decision and the behaviors needed for successful implementation. However, scholars have only recently begun to focus on the de-adoption or de-implementation of low-value programs and practices to make room for evidence-based alternatives. This study introduces escalation of commitment as a theoretical framework for understanding why school administrators may stick with ineffective programs and practices. Escalation of commitment is a robust decision-making bias in which people feel compelled to continue with a course of action even when performance indicators suggest it is not going well. Using grounded theory methodology, we conducted semi-structured interviews with 24 building- and district-level school administrators in the Midwestern United States. Results suggested that escalation of commitment occurs when administrators attribute the underlying causes of poor program performance not to the program itself but instead to issues related to implementation, leadership, or the limitations of the performance indicators themselves. We also identified a variety of psychological, organizational, and external determinants that accentuate administrators' continuance of ineffective prevention programs. Based on our findings, we highlight several contributions to theory and practice.

Implementation of nonpharmacologic physical restraint minimization interventions in the adult intensive care unit: A scoping review

OBJECTIVE

To identify the elements informing the successful implementation of nonpharmacologic physical restraint minimization interventions in adult intensive care unit patients. To map those elements to innovation, context, recipients and facilitation domains of the integrated-Promoting Action on Research Implementation in Health Services (i-PARIHS) framework and to describe the outcomes of those interventions.

METHODOLOGY

A scoping review of studies published in English reporting on restraint minimization interventions in adult intensive care units. We searched seven databases (MEDLINE, CIHAHL, Embase, Web of Science, Cochrane Library, PROSPERO and Joanna Briggs) from inception to 2021. Two authors independently screened articles for inclusion, extracted study characteristics and mapped intervention data to the i-PARIHS domains.

RESULTS

Seven studies met inclusion criteria. Innovations comprised multicomponent interventions including education, decision aids/protocols and restraint alternatives. No studies utilised an implementation science framework to diagnose the baseline practice context. A commonly reported barrier to restraint minimization was a risk averse culture. Change was mostly driven by the external context (i.e. national regulations). Overall, nurses were the primary facilitators and recipients of practice change. Outcomes were changes in restraint incidence and prevalence abstracted from the medical record. However, no study validated the accuracy of restraint documentation. All studies documented an initial decrease in physical restraint use, but no long-term results were reported.

CONCLUSION

Restraint minimization intervention studies report nurse-facilitated multicomponent interventions and short-term practice change. Future restraint minimization research incorporating implementation science frameworks, interprofessional teams and patient/family perspectives is warranted.

A Health Systems Ethical Framework for De-implementation in Health Care

INTRODUCTION

Unnecessary health care not only drive up costs, but also contribute to avoidable patient harms, underscoring an ethical obligation to eliminate practices which are harmful, lack evidence, and prevent spending on more beneficial services. To date, de-implementation ethics discussions have been limited and focused on clinical ethics principles. An analysis of de-implementation ethics in the broader context of the health care system is lacking.

METHODS

To better understand the ethical considerations of de-implementation, recognizing it as a health care systems issue, we applied Krubiner and Hyder's bioethical framework for health systems activity. We examine ethics principles relevant to de-implementation, which either call for or facilitate the reduction of low value surgery.

RESULTS AND DISCUSSION

From 11 health systems principles proposed by Krubiner and Hyder, we identified the 5 principles most pertinent to the topic of de-implementation: evidence and effectiveness, transparency and public engagement, efficiency, responsiveness, and collaboration. An analysis of de-implementation through the lens of these principles not only supports de-implementation but proves an obligation at the health system level to eliminate low value care. Recognizing the challenge of defining "value," the proposed framework may increase the legitimacy and objectivity of de-implementation.

CONCLUSIONS

While there is no single ideal ethical framework from which to approach de-implementation, a health systems framework allows for consideration of the systems-level factors impacting de-implementation. Framing de-implementation as a health systems issue with systems-wide ethical implications empowers providers to think about new ways to approach potential roadblocks to reducing low-value care.

Better Service by Doing Less: Introducing De-implementation Research in HIV

The course of HIV research has led to a multitude of interventions to prevent and treat HIV. With the arrival of more effective interventions comes the need to end, or de-implement, less effective interventions. PURPOSE OF REVIEW: To describe the state of de-implementation research in HIV and provide a rationale for expanded research in this area. RECENT FINDINGS: Existing studies have identified a set of HIV-specific interventions appropriate for de-implementing and described the persistence of interventions that should be ended. However, to our knowledge, strategies to successfully promote appropriate de-implementation of HIV-specific interventions have not been examined. De-implementing interventions that are no longer needed is an opportunity to improve the quality and effectiveness of HIV services. Opportunities to expand this field of research abound.

Formulating an Ethics of Pharmaceutical Disinvestment

There is growing interest among pharmaceutical policymakers in how to "disinvest" from subsidized medicines. This is due to both the rapidly rising costs of healthcare and the increasing use of accelerated and conditional reimbursement pathways which mean that medicines are being subsidized on the basis of less robust evidence of safety and efficacy. It is crucial that disinvestment decisions are morally sound and socially legitimate, but there is currently no framework to facilitate this. We therefore reviewed the bioethics literature in order to identify ethical principles and concepts that might be relevant to pharmaceutical disinvestment decisions. This revealed a number of key ethical considerations-both procedural and substantive-that need to be considered when making pharmaceutical disinvestment decisions. These principles do not, however, provide practical guidance so we present a framework outlining how they might be applied to different types of disinvestment decisions. We also argue that, in this context, even the most rigorous ethical reasoning is likely to be overridden by moral intuitions and psychological biases and that disinvestment decisions will need to strike the right balance between respecting justifiable moral intuitions and overriding unjustifiable psychological impulses.

Factors influencing current low-value follow-up care after basal cell carcinoma and suggested strategies for de-adoption: a qualitative study

BACKGROUND

Providing follow-up to patients with low-risk basal cell carcinoma (BCC) can be considered as low-value care. However, dermatologists still provide substantial follow-up care to this patient group, for reasons not well understood.

OBJECTIVES

To identify factors influencing current BCC follow-up practices among dermatologists and suggested strategies to de-adopt this low-value care. In addition, views of patients regarding follow-up care were explored.

METHODS

A qualitative study was conducted consisting of 18 semistructured interviews with dermatologists and three focus groups with a total of 17 patients with low-risk BCC who had received dermatological care. The interviews focused on current follow-up practices, influencing factors and suggested strategies to de-adopt the follow-up care. The focus groups discussed preferred follow-up schedules and providers, as well as the content of follow-up. All (group) interviews were transcribed verbatim and analysed by two researchers using ATLAS.ti software.

RESULTS

Factors influencing current follow-up care practices among dermatologists included complying with patients' preferences, lack of trust in general practitioners (GPs), financial incentives and force of habit. Patients reported varying needs regarding periodic follow-up visits, preferred to be seen by a dermatologist and indicated a need for improved information provision. Suggested strategies by dermatologists to de-adopt the low-value care encompassed educating patients with improved information, educating GPs to increase trust of dermatologists, realizing appropriate financial reimbursement and informing dermatologists about the low value of care.

CONCLUSIONS

A mixture of factors appear to contribute to current follow-up practices after low-risk BCC. In order to de-adopt this low-value care, strategies should be aimed at dermatologists and GPs, and also patients.

An assessment of the risk, cost-effectiveness, and perceived benefits of anti-parvovirus B19 tested blood products

BACKGROUND

Parvovirus B19 (B19V) can cause severe anemia, hydrops foetalis, and even death in vulnerable patients. To prevent transfusion-transmitted B19V infection of at-risk patients, B19V antibody screening of blood donors was implemented. The cost-effectiveness of this intervention is unclear, as the likelihood of transmission through blood and subsequent complications for recipients are unknown. This study estimates the cost-effectiveness of anti-B19V donor screening in the Netherlands.

STUDY DESIGN AND METHODS

The estimates needed for the cost-effectiveness model were: the occurrence of B19V in Dutch blood donors, the number of anti-B19V tested products required by hospitals, the likelihood of morbidity and mortality given B19V infection, treatment costs, and screening costs. These estimates were obtained from literature and observational data. When data were unavailable, structured expert judgment elicitation and statistical modeling were applied.

RESULTS

The costs of preventing one transfusion transmitted B19V infection are estimated at €68,942 (€42,045 - €102,080). On average, 1.25 cases of morbidity and 0.12 cases of mortality are prevented annually. Although the perceived risk of transfusion transmitted B19V infection was low, half of the treating physicians favored anti-B19V screening.

CONCLUSION

The estimated mortality and morbidity caused by B19V infection was low in the risk groups. The cost-effectiveness ratio is similar to other blood safety screening measures. No guidance exists to evaluate the acceptability of this ratio. The explicit overview of costs and effects may further guide the discussion of the desirability of B19V safe blood products.

Active change interventions to de-implement low-value healthcare practices: a scoping review protocol

BACKGROUND

There is recognition that the overuse of procedures, tests and medications strains the healthcare system financially and can cause unnecessary stress and harm to patients. In recent years, several initiatives have targeted the reduction or elimination of low-value practices in healthcare. Research suggests that passive interventions, such as the publication of guidelines, are often not sufficient to change behaviour and that active change interventions - interventions which actively implement strategies to change practices - are required to effect significant, sustained practice change. The purpose of this scoping review is to identify and characterise studies of active change interventions designed to reduce or eliminate low-value healthcare practices.

METHODS

We will conduct a review of MEDLINE, EMBASE, CINAHL and Scopus databases from inception. Building on previous research, 40 key terms will be used to search literature. The screening process will be conducted separately by two researchers, with discrepancies resolved by a third. Empirical studies of active change interventions used to reduce or eliminate low-value practices will be included. Descriptive statistics and thematic analysis will be used to categorise the characteristics of the studies.

ETHICS AND DISSEMINATION

Ethics approval is not required for this study. This scoping review will provide insights into the impact of several characteristics of active change interventions, including the number of interventions (single-faceted or multifaceted) and the level of implementation (individual or organisational). These results can provide guidance and direction for future research in de-implementation. The results will be disseminated through presentations at national and international conferences and the publication of a manuscript.

De-implementation: A concept analysis

AIM

The purpose of this concept analysis is to explore the meaning of de-implementation and provide a definition that can be used by researchers and clinicians to facilitate evidence-based practice.

BACKGROUND

De-implementation is a relatively unknown process overshadowed by the novelty of introducing new ideas and techniques into practice. Few studies have addressed the challenge of de-implementation and the cognitive processes involved when terminating harmful or unnecessary practices. Also, confusion exists regarding the myriad of terms used to describe de-implementation processes.

DESIGN

Walker and Avant's method (2011) for describing concepts was used to clarify de-implementation.

DATA SOURCE

A database search limited to academic journals yielded 281 publications representing basic research, study protocols, and editorials/commentaries from implementation science experts. After applying exclusion criterion of English language only and eliminating overlap between databases, 41 articles were selected for review.

REVIEW METHODS

Literature review and synthesis provided a concept analysis and a distinct definition of de-implementation.

RESULTS

De-implementation was defined as the process of identifying and removing harmful, non-cost-effective, or ineffective practices based on tradition and without adequate scientific support.

CONCLUSIONS

The analysis provided further refinement of de-implementation as a significant concept for ongoing theory development in implementation science and clinical practice.

Classification schemes for knowledge translation interventions: a practical resource for researchers

BACKGROUND

As implementation science advances, the number of interventions to promote the translation of evidence into healthcare, health systems, or health policy is growing. Accordingly, classification schemes for these knowledge translation (KT) interventions have emerged. A recent scoping review identified 51 classification schemes of KT interventions to integrate evidence into healthcare practice; however, the review did not evaluate the quality of the classification schemes or provide detailed information to assist researchers in selecting a scheme for their context and purpose. This study aimed to further examine and assess the quality of these classification schemes of KT interventions, and provide information to aid researchers when selecting a classification scheme.

METHODS

We abstracted the following information from each of the original 51 classification scheme articles: authors' objectives; purpose of the scheme and field of application; socioecologic level (individual, organizational, community, system); adaptability (broad versus specific); target group (patients, providers, policy-makers), intent (policy, education, practice), and purpose (dissemination versus implementation). Two reviewers independently evaluated the methodological quality of the development of each classification scheme using an adapted version of the AGREE II tool. Based on these assessments, two independent reviewers reached consensus about whether to recommend each scheme for researcher use, or not.

RESULTS

Of the 51 original classification schemes, we excluded seven that were not specific classification schemes, not accessible or duplicates. Of the remaining 44 classification schemes, nine were not recommended. Of the 35 recommended classification schemes, ten focused on behaviour change and six focused on population health. Many schemes (n = 29) addressed practice considerations. Fewer schemes addressed educational or policy objectives. Twenty-five classification schemes had broad applicability, six were specific, and four had elements of both. Twenty-three schemes targeted health providers, nine targeted both patients and providers and one targeted policy-makers. Most classification schemes were intended for implementation rather than dissemination.

CONCLUSIONS

Thirty-five classification schemes of KT interventions were developed and reported with sufficient rigour to be recommended for use by researchers interested in KT in healthcare. Our additional categorization and quality analysis will aid in selecting suitable classification schemes for research initiatives in the field of implementation science.

Studying de-implementation in health: an analysis of funded research grants

BACKGROUND

Studying de-implementation-defined herein as reducing or stopping the use of a health service or practice provided to patients by healthcare practitioners and systems-has gained traction in recent years. De-implementing ineffective, unproven, harmful, overused, inappropriate, and/or low-value health services and practices is important for mitigating patient harm, improving processes of care, and reducing healthcare costs. A better understanding of the state-of-the-science is needed to guide future objectives and funding initiatives. To this end, we characterized de-implementation research grants funded by the United States (US) National Institutes of Health (NIH) and the Agency for Healthcare Research and Quality (AHRQ).

METHODS

We used systematic methods to search, identify, and describe de-implementation research grants funded across all 27 NIH Institutes and Centers (ICs) and AHRQ from fiscal year 2000 through 2017. Eleven key terms and three funding opportunity announcements were used to search for research grants in the NIH Query, View and Report (QVR) system. Two coders identified eligible grants based on inclusion/exclusion criteria. A codebook was developed, pilot tested, and revised before coding the full grant applications of the final sample.

RESULTS

A total of 1277 grants were identified through the QVR system; 542 remained after removing duplicates. After the multistep eligibility assessment and review process, 20 grant applications were coded. Many grants were funded by NIH (n = 15), with fewer funded by AHRQ, and a majority were funded between fiscal years 2015 and 2016 (n = 11). Grant proposals focused on de-implementing a range of health services and practices (e.g., medications, therapies, screening tests) across various health areas (e.g., cancer, cardiovascular disease) and delivery settings (e.g., hospitals, nursing homes, schools). Grants proposed to use a variety of study designs and research methods (e.g., experimental, observational, mixed methods) to accomplish study aims.

CONCLUSIONS

Based on the systematic portfolio analysis of NIH- and AHRQ-funded research grants over the past 17 years, relatively few have focused on studying the de-implementation of ineffective, unproven, harmful, overused, inappropriate, and/or low-value health services and practices provided to patients by healthcare practitioners and systems. Strategies for raising the profile and growing the field of research on de-implementation are discussed.