Objective: To explore how best to deimplement nonrecommended medical services, which can result in excess costs and patient harm.
Methods: We conducted telephone interviews with 15 providers at 3 health systems from June 19 to November 21, 2017. Using the case of nonrecommended imaging in patients with cancer, participants assessed the potential for 7 rationales or "arguments," each characterizing overuse in terms of a single problem type (cost or quality) and affected stakeholder group (clinicians, institutions, society, or patients), to convince colleagues to change their practices. We tested rationales for all problem-stakeholder combinations appearing in prior deimplementation studies.
Results: Participants' views varied widely. Relatively few found cost arguments powerful, except for patients' out-of-pocket costs. Participants were divided on institution-quality and clinician-quality rationales. Patient-quality rationales resonated strongly with nearly all participants. However, a "yes, but" phenomenon emerged: after initially expressing strong support for a rationale, participants often undercut it with denials or rationalizations.
Conclusion: Deimplementation efforts should combine multiple rationales appealing to clinicians' diverse perspectives and priorities. In addition, efforts must consider the complex cognitive dynamics that can undercut data and reasoned argumentation.
Keywords: APRN, advanced practice registered nurse; HHCI, Hartford HealthCare Cancer Institute; LVHN, Lehigh Valley Healthcare Network; MD, physician; MSK, Memorial Sloan Kettering; NP, nurse practitioner.
© 2020 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc.