PDF(Pubmed)
Abstract：
OBJECTIVE: Considerable efforts have been made to improve guideline adherence in healthcare through de-implementation, such as decreasing the prescription of inappropriate medicines. However, we have limited knowledge about the effectiveness, barriers, facilitators and consequences of de-implementation strategies targeting inappropriate medication prescribing in secondary care settings. This review was conducted to understand these factors to contribute to better replication and optimisation of future de-implementation efforts to reduce low-value care.
METHODS: A systematic review of randomised control trials was conducted. Papers were identified through CINAHL, EMBASE, MEDLINE and Cochrane register of controlled trials to February 2021. Eligible studies were randomised control trials evaluating behavioural strategies to de-implement inappropriate prescribing in secondary healthcare. Risk of bias was assessed using the Cochrane Risk of Bias tool. Intervention characteristics, effectiveness, barriers, facilitators and consequences were identified in the study text and tabulated.
RESULTS: Eleven studies were included, of which seven were reported as effectively de-implementing low-value prescribing. Included studies were judged to be mainly at low to moderate risk for selection biases and generally high risk for performance and reporting biases. The majority of these strategies were clinical decision support at the \'point of care\'. Clinical decision support tools were the most common and effective. They were found to be a low-cost and simple strategy. However, barriers such as clinician\'s reluctance to accept recommendations, or the clinical setting were potential barriers to their success. Educational strategies were the second most reported intervention type however the utility of educational strategies for de-implementation remains varied. Multiple barriers and facilitators relating to the environmental context, resources and knowledge were identified across studies as potentially influencing de-implementation. Various consequences were identified; however, few measured the impact of de-implementation on usual appropriate practice.
CONCLUSIONS: This review offers insight into the intervention strategies, potential barriers, facilitators and consequences that may affect the de-implementation of low-value prescribing in secondary care. Identification of these key features helps understand how and why these strategies are effective and the wider (desirable or undesirable) impact of de-implementation. These findings can contribute to the successful replication or optimisation of strategies used to de-implement low-value prescribing practices in future.
BACKGROUND: The review protocol was registered at PROSPERO (ID: CRD42021243944).
METHODS: A systematic review of randomised control trials was conducted. Papers were identified through CINAHL, EMBASE, MEDLINE and Cochrane register of controlled trials to February 2021. Eligible studies were randomised control trials evaluating behavioural strategies to de-implement inappropriate prescribing in secondary healthcare. Risk of bias was assessed using the Cochrane Risk of Bias tool. Intervention characteristics, effectiveness, barriers, facilitators and consequences were identified in the study text and tabulated.
RESULTS: Eleven studies were included, of which seven were reported as effectively de-implementing low-value prescribing. Included studies were judged to be mainly at low to moderate risk for selection biases and generally high risk for performance and reporting biases. The majority of these strategies were clinical decision support at the \'point of care\'. Clinical decision support tools were the most common and effective. They were found to be a low-cost and simple strategy. However, barriers such as clinician\'s reluctance to accept recommendations, or the clinical setting were potential barriers to their success. Educational strategies were the second most reported intervention type however the utility of educational strategies for de-implementation remains varied. Multiple barriers and facilitators relating to the environmental context, resources and knowledge were identified across studies as potentially influencing de-implementation. Various consequences were identified; however, few measured the impact of de-implementation on usual appropriate practice.
CONCLUSIONS: This review offers insight into the intervention strategies, potential barriers, facilitators and consequences that may affect the de-implementation of low-value prescribing in secondary care. Identification of these key features helps understand how and why these strategies are effective and the wider (desirable or undesirable) impact of de-implementation. These findings can contribute to the successful replication or optimisation of strategies used to de-implement low-value prescribing practices in future.
BACKGROUND: The review protocol was registered at PROSPERO (ID: CRD42021243944).
摘要：
目标：已经做出了相当大的努力，通过取消实施来提高医疗保健指南的依从性，例如减少不适当药物的处方。然而,我们对有效性的了解有限，障碍,在二级保健环境中针对不适当药物处方的取消实施策略的促进因素和后果。进行这篇综述是为了了解这些因素，以有助于更好地复制和优化未来的去实施工作，以减少低价值护理。
方法：对随机对照试验进行系统评价。论文通过CINAHL进行鉴定，EMBASE,截至2021年2月，MEDLINE和Cochrane进行了对照试验登记。符合条件的研究是随机对照试验，评估行为策略，以取消二级医疗保健中不适当的处方。使用Cochrane偏差风险工具评估偏差风险。干预特点,有效性,障碍,研究文本中确定了促进因素和结果,并将其制成表格.
结果：纳入了11项研究，其中7项被报告为有效取消低价值处方。纳入的研究被认为主要处于选择偏差的低至中等风险，以及通常表现和报告偏差的高风险。这些策略中的大多数是在“护理点”的临床决策支持。临床决策支持工具是最常见和最有效的。他们被发现是一种低成本和简单的策略。然而,障碍，如临床医生不愿接受建议，或临床环境是他们成功的潜在障碍。教育策略是第二大报告的干预类型，但是教育策略用于取消实施的效用仍然各不相同。与环境背景有关的多重障碍和促进者，在研究中，资源和知识被确定为可能影响取消实施的因素。确定了各种后果；然而，很少有人衡量取消实施对通常适当做法的影响。
结论：这篇综述提供了对干预策略的见解，潜在的障碍,可能影响二级保健中低价值处方的取消实施的促进因素和后果。识别这些关键特征有助于理解这些策略如何以及为什么是有效的以及取消实施的更广泛的(期望的或不期望的)影响。这些发现有助于成功复制或优化未来用于取消低价值处方实践的策略。
背景：审查方案已在PROSPERO注册（ID：CRD42021243944）。
方法：对随机对照试验进行系统评价。论文通过CINAHL进行鉴定，EMBASE,截至2021年2月，MEDLINE和Cochrane进行了对照试验登记。符合条件的研究是随机对照试验，评估行为策略，以取消二级医疗保健中不适当的处方。使用Cochrane偏差风险工具评估偏差风险。干预特点,有效性,障碍,研究文本中确定了促进因素和结果,并将其制成表格.
结果：纳入了11项研究，其中7项被报告为有效取消低价值处方。纳入的研究被认为主要处于选择偏差的低至中等风险，以及通常表现和报告偏差的高风险。这些策略中的大多数是在“护理点”的临床决策支持。临床决策支持工具是最常见和最有效的。他们被发现是一种低成本和简单的策略。然而,障碍，如临床医生不愿接受建议，或临床环境是他们成功的潜在障碍。教育策略是第二大报告的干预类型，但是教育策略用于取消实施的效用仍然各不相同。与环境背景有关的多重障碍和促进者，在研究中，资源和知识被确定为可能影响取消实施的因素。确定了各种后果；然而，很少有人衡量取消实施对通常适当做法的影响。
结论：这篇综述提供了对干预策略的见解，潜在的障碍,可能影响二级保健中低价值处方的取消实施的促进因素和后果。识别这些关键特征有助于理解这些策略如何以及为什么是有效的以及取消实施的更广泛的(期望的或不期望的)影响。这些发现有助于成功复制或优化未来用于取消低价值处方实践的策略。
背景：审查方案已在PROSPERO注册（ID：CRD42021243944）。
