109 The use of theories and frameworks to understand and address the reduction of low-value healthcare practices: a scoping review

Background There is recognition that the overuse of procedures, testing and medications strains the healthcare system financially and can cause unnecessary stress and harm for patients. In recent years, several initiatives—such as Choosing Wisely—have targeted the reduction or elimination of low-value practices in healthcare. Researchers have begun to use theory or develop frameworks to elucidate the dynamics of de-implementation and support efforts to reduce low-value practices. The purpose of this scoping review was to identify and characterize the use of theories and frameworks to understand and address the reduction of low-value healthcare practices. Methods We conducted a systematic review of MEDLINE, EMBASE, CINAHL and Scopus databases from inception to January 2018. Building on previous research, 44 key terms were used to search the literature. To be included, papers had to present an explicit theoretical approach or framework. The database searches identified 725 unique articles for which titles and abstracts were screened for inclusion; 74 items were selected for full text review. Results Forty studies met the inclusion criteria. Over 50% of included articles were published in the last two years. Of studies which used a theoretical approach, the majority used psychological theories, such as the Theory of Planned Behaviour or applied behavioural science concepts to develop interventions. The included studies demonstrated a maturating of the use of theory in this field, with a progression from the use of classic theories to multi-theory frameworks to dual processing models. Theories or frameworks were used primarily to identify barriers and facilitators or develop conceptual clarity. Articles used theory to understand how provider decision-making, knowledge or perceptions of social pressure play a role in overuse. The majority of studies addressed low-value care at the provider level. Antibiotic overuse, polypharmacy and appropriate prescribing were the practices targeted most frequently in the included studies. Conclusions De-implementation is an emerging field of research. This scoping review was the first to review the use of theory in efforts to reduce low-value practice. The results of this review can provide direction and insight for future primary research in the use of theory to support de-implementation and reduction of low-value healthcare practices.