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Table 1 Overview of complexities of de-implementation and sample research questions

From: Unpacking the complexities of de-implementing inappropriate health interventions

Multi-level factorsCharacteristicsSample research questions
 InterventionStrength of evidenceWhat happens if the strength of the evidence for an intervention changes during a de-implementation trial?
ComplexityAre simpler interventions easier to de-implement than more complex interventions?
 PatientAnxiety, fear, and worryWhat are some predictors of patients’ level of anxiety in anticipation of no longer receiving an intervention?
Inaccurate beliefs and social normsWhat are some common misperceptions about de-implementation among patients?
Distrust of medical establishmentUnder what conditions might de-implementation lead to patients’ distrust of health professionals?
 Health professionalNegative past eventsWhat is the relationship between severity of negative past events, frequency of negative past events, and health professionals’ willingness to de-implement?
Cognitive dissonanceWhat are some predictors of health professionals who experience cognitive dissonance?
Fear of medical malpracticeWhat differentiates health professionals who fear medical malpractice and engage in defensive medicine from those who do not?
 OrganizationRevenueWhy do some organizations embrace the de-implementation of revenue-generating interventions whereas others resist?
Competitive advantageWho is involved in making decisions to market an intervention for which the strength of the evidence is mixed, and how are those decisions made?
LiabilityIs there a liability threshold above which organizations are less likely to de-implement an intervention?
Types of actionDescriptionSample research questions
 RemoveStop delivering an inappropriate interventionHow does one determine the pace at which an intervention should be removed?
 ReplaceReplace a currently delivered inappropriate intervention with a new, evidence-based intervention targeting the same or similar patient outcomesWhat are the minimum criteria for deciding when to replace one intervention with another?
 ReduceReduce (frequency and/or intensity) use of an inappropriate interventionIs it more difficult to reduce both the frequency and intensity of an intervention versus only the frequency or intensity of an intervention?
 RestrictNarrow to whom, by whom, and/or where the intervention is deliveredWhat are some of the unintended negative consequences of restricting the delivery setting in which an intervention is delivered?
Multi-level targetsPotential strategiesSample research questions
 PatientAffective-based interventions to reduce anxiety, fear, and worryWhat role can caregivers play in reducing patients’ fear of missing a diagnosis?
 Health professionalMedical malpractice tort reformCan medical malpractice tort reform reduce defensive medicine? Is tort reform more effective in some specialties or for some types of interventions than others?
 OrganizationIdentify alternative sources of revenueWhat toolkits can help organizations identify alternative sources of revenue that will facilitate de-implementation?
  1. Note: This is not a comprehensive list of all factors that affect de-implementation but rather a summary of those that may be particularly applicable or unique to de-implementation of inappropriate health interventions as compared to implementation of new, evidence-based health interventions