Table 3 Characteristics of interventions implemented to de-implement low-value care in cancer care delivery

Durieux et al. (2003) [38]

A specific laboratory order form with clinical guidelines to improve appropriate test orders.

The number of tumor markers prescribed, and the ratio tumor markers/admissions decreased in the hospital (p < .0001), and in the Departments of Gastroenterology (p < .0001) and Internal Medicine (p < .01).

Local adaptation of guidelines by those who are going to use them, implementation strategy for guidelines, and scientific knowledge concerning the utility of different markers.

Miller et al. (2011) [43]

A multistep intervention including (1) audit and comparative performance feedback, (2) having a clinical champion, (3) dissemination of clinical guidelines, and (4) establishing the Urological Surgery Quality Collaborative as an infrastructure for physician led, collaborative quality improvement in urology.

Compared with baseline practice patterns (31% bone scans, 28% computerized tomography), urologists in Urological Surgery Quality Collaborative practices ordered fewer bone and computerized tomography scans in post-intervention phases 2 (23%, 21%) and 3 (16%, 13%) of data collection (p < 0.01), including a significant reduction in the use of these studies in patients with low and intermediate risk cancer (p < 0.05).

Not reported

Butler et al. (2015) [37]

Computerized physician order entry systems have been integrated with a clinical decision support system software to improve compliance with restrictive blood management protocols. Such systems require physicians to specify the indication for blood product transfusion and highlight to the clinician the requests that lie outside prespecified guidelines for transfusion by linking them to the most recent laboratory results. In addition, extensive, real-time education, support, and feedback were provided to clinicians.

There was no significant difference in (1) the mean number of transfusions per patient, (2) the proportion of patients transfused, (3) post-transfusion hemoglobin (Hb), and (4) pre- and post-transfusion PLT count, although mean pretransfusion Hb decreased. The proportion of noncompliant RBC and PLT transfusion requests improved from baseline to CDSS2 (69.0 to 43.4% p < 0.005 for RBCs, and 41.9 to 31.2%, p = 0.16 for PLT).

The amount of time and human resources required to provide monitoring, analysis, and feedback, and provider reluctance.

Ross et al. (2015) [39]

A multistep intervention including (1) audit and performance feedback, (2) having a clinical champion.

Bone scan decreased from 3.7 to 1.3% (p = 0.03), and computerized tomography decreased from 5.2 to 3.2% (p = 0.17).

Not reported

Shelton et al. (2015) [40]

A clinical computerized decision support (CCDS) tool to remind providers of current recommendations against PSA-based prostate cancer screening for men 75 and older. A pop-up message to alert providers ordering a screening PSA test in a patient 75 years of age or older. When triggered, a brief interruptive educational message was shown on the ordering screen.

The mean monthly screening rate decreased from 8.3 to 4.6%. The screening rate declined by 38% during the baseline period and by 40% and 30%, respectively, during the two periods when the CCDS tool was turned on. The screening rate ratios for the baseline and two periods when the CCDS tool was on were 0.97, 0.78, and 0.90, respectively, with a significant difference between baseline and the first CCDS-on period (p < 0.0001), and a trend toward a difference between baseline and the second CCDS-on period (p = 0.056).

The alert fatigue, difficulty in changing providers’ behavior, and the rotation of resident physician staff

Martin Goodman et al. (2016) [42]

Three Plan-Do-Study-Act cycles, educated providers about the appropriate use and cost of pGCSF, developed the Cleveland Clinic consensus guidelines, removed primary prophylactic pGCSF from LRCR EMR orders.

The percentage of patients who received inappropriate primary prophylactic pGCSF and the number of doses per patient decreased significantly. Cost analysis showed an average 86% decrease in billed charges per month, which would result in $408,000 in annual savings based on the current CMS allowable payment per dose.

Not reported

Sheridan et al. (2016) [32]

One-page, written evidence-based decision support sheet.

Intentions to accept screening were high before the intervention and change in intentions did not differ across intervention arms (words, − 0.07; numbers, − 0.05; numbers plus narrative, − 0.12; numbers plus framed presentation, − 0.02; P = .57 for all comparisons). Change in other outcomes also showed no difference across intervention arms.

Not reported

Hill et al. (2018) [33]

A planned implementation strategy using levels of the National Quality Strategy including (1) learning and technical assistance, (2) measurement and feedback, (3) certification, accreditation, and regulation, (4) innovation and diffusion (of quality improvement strategies), (5) workforce development, (6) patient education, (7) reward providers, and (8) modify the existing electronic medical record synoptic documentation template.

The overall rate of compliance with guidelines for ordering a CBC and LFT was 82% and 87%, respectively. Segregated by the pre- and post-guideline change time period, the compliance rates for ordering a CBC and LFT were 78% and 87% (P = 0.076).

(1) Integrated health care systems, (2) resource availability (e.g., electronic medical records and funding for academic research assistants)

Gob et al. (2019) [41]

A multistep intervention including (1) a root cause analysis targeted at discovering contributing factors to two-unit transfusion orders, including a retrospective audit of the previous month’s two-unit transfusions, structured brain-storming by the study authors, and focused interviews with house staff and attending physicians. (2) An educational campaign with an educational email, and a Grand Rounds presentation focusing on improving awareness of the Choosing Wisely guidelines. (3) A real-time audit and feedback, (4) focused oncologist interviews, (5) modify the transfusion orders setting.

Modifying the transfusion orders templates was the only intervention that resulted in an immediate and sustained change to the system. Post-intervention, the mean proportion of one-unit transfusions rose to 86.0% and was sustained for the 17 months of ongoing data collection.

Bias inertia toward low-value care (i.e., status quo bias)

Hoque et al. (2020) [36]

FDA black box warnings and risk evaluation monitoring strategies

ESA use for epoetin fell from 22 to 1%, and for darbepoetin fell from 11 to 1% (p < 0.01). Mean hematocrit levels at ESA initiation decreased from 30 to 21% (p < 0.01).

National policies and regulatory decisions, patient consent

Ciprut et al. (2020) [35]

Using the National Comprehensive Cancer Network’s guidelines, a Clinical Reminder Order Check (CROC) that alerts ordering providers of potentially inappropriate imaging orders in real-time based on patient features of men diagnosed with low-risk prostate cancer

The percentage of the men who were staged according to guidelines increased from 65 to 81%. Inappropriate imaging of men with low-risk prostate cancer was reduced by 16%.

Not reported

Laan et al. (2020) [34]

A tailored multi- faceted intervention incudes an assessment of determinants of practice for inappropriate catheter use nurse education, physician champion, empowerment of nurses depending on the local situation of the participating hospital, audit and feedback, and additional interventions such as smart phrase for the daily patient report in electronic health records.

Inappropriate use of peripheral intravenous catheters decreased from 22.0 to 14.4% (incidence rate ratio [IRR] 0.65, 95% CI 0·56 to 0.77, p < 0·0001). An absolute reduction in inappropriate use of peripheral intravenous catheters from baseline to intervention periods of 6.65% (95% CI 2.47 to 10.82, p = 0·011). Inappropriate use of urinary catheters decreased from 32.4 to 24.1% (IRR 0.74, 95% CI 0.56 to 0.98, p = 0·013). An absolute reduction in inappropriate use of urinary catheters of 6.34% (95% CI – 12.46 to 25.13, p = 0·524).

Piloting the intervention, developing evidence-based and consensus-driven criteria for appropriate use of peripheral intravenous catheters