Table 1 Overview of complexities of de-implementation and sample research questions
From: Unpacking the complexities of de-implementing inappropriate health interventions
Multi-level factors | Characteristics | Sample research questions |
|---|---|---|
 Intervention | Strength of evidence | What happens if the strength of the evidence for an intervention changes during a de-implementation trial? |
Complexity | Are simpler interventions easier to de-implement than more complex interventions? | |
 Patient | Anxiety, fear, and worry | What are some predictors of patients’ level of anxiety in anticipation of no longer receiving an intervention? |
Inaccurate beliefs and social norms | What are some common misperceptions about de-implementation among patients? | |
Distrust of medical establishment | Under what conditions might de-implementation lead to patients’ distrust of health professionals? | |
 Health professional | Negative past events | What is the relationship between severity of negative past events, frequency of negative past events, and health professionals’ willingness to de-implement? |
Cognitive dissonance | What are some predictors of health professionals who experience cognitive dissonance? | |
Fear of medical malpractice | What differentiates health professionals who fear medical malpractice and engage in defensive medicine from those who do not? | |
 Organization | Revenue | Why do some organizations embrace the de-implementation of revenue-generating interventions whereas others resist? |
Competitive advantage | Who is involved in making decisions to market an intervention for which the strength of the evidence is mixed, and how are those decisions made? | |
Liability | Is there a liability threshold above which organizations are less likely to de-implement an intervention? | |
Types of action | Description | Sample research questions |
 Remove | Stop delivering an inappropriate intervention | How does one determine the pace at which an intervention should be removed? |
 Replace | Replace a currently delivered inappropriate intervention with a new, evidence-based intervention targeting the same or similar patient outcomes | What are the minimum criteria for deciding when to replace one intervention with another? |
 Reduce | Reduce (frequency and/or intensity) use of an inappropriate intervention | Is it more difficult to reduce both the frequency and intensity of an intervention versus only the frequency or intensity of an intervention? |
 Restrict | Narrow to whom, by whom, and/or where the intervention is delivered | What are some of the unintended negative consequences of restricting the delivery setting in which an intervention is delivered? |
Multi-level targets | Potential strategies | Sample research questions |
 Patient | Affective-based interventions to reduce anxiety, fear, and worry | What role can caregivers play in reducing patients’ fear of missing a diagnosis? |
 Health professional | Medical malpractice tort reform | Can medical malpractice tort reform reduce defensive medicine? Is tort reform more effective in some specialties or for some types of interventions than others? |
 Organization | Identify alternative sources of revenue | What toolkits can help organizations identify alternative sources of revenue that will facilitate de-implementation? |