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Raudasoja, A.J., Falkenbach, P., Vernooij, R.W.M. et al. Randomized controlled trials in de-implementation research: a systematic scoping review. Implementation Sci 17, 65 (2022).

Randomized controlled trials in de-implementation research : a systematic scoping review

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Author: Raudasoja, Aleksi J.1,2; Falkenbach, Petra3,4; Vernooij, Robin W. M.5,6;
Organizations: 1Faculty of Medicine, University of Helsinki, Helsinki, Finland
2Finnish Medical Society Duodecim, Helsinki, Finland
3Finnish Coordinating Center for Health Technology Assessment, Oulu University Hospital, Oulu, Finland
4University of Oulu, Oulu, Finland
5Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
6Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
7Occupational Health Helsinki, Helsinki, Finland
8Division of General Internal Medicine, Department of Medicine and Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
9Department of Urology, University of Fukui Faculty of Medical Sciences, Fukui, Japan
10Department of General Practice and Elderly Care Medicine, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
11Department of Gynaecology, Chelsea & Westminster NHS Foundation Trust, London, UK
12Department of Epidemiology & Biostatistics, Imperial College London, London, UK
13Division of Urology/Uro-oncology, Department of Surgery, School of Medicine, Universidad del Valle, Cali, Colombia
14Department of Urology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
15Department of Radiology, Tampere University Hospital and Faculty of Medicine and Health Technologies, Tampere University, Tampere, Finland
16Hatanpää Health Center, City of Tampere, Finland
17Unit of Health Sciences, Faculty of Social Sciences, Tampere University, Tampere, Finland
18Oral Health Care, Tampere, Finland
19Institute of Dentistry, University of Eastern Finland, Kuopio, Finland
20Nordic Healthcare Group Ltd., Helsinki, Finland
21Division of Urology, Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Canada
22Departments of Surgery and Health Research Methods Evidence and Impact, McMaster University, Hamilton, Canada
23Department of Surgery, South Karelian Central Hospital, Lappeenranta, Finland
Format: article
Version: published version
Access: open
Online Access: PDF Full Text (PDF, 1.4 MB)
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Language: English
Published: Springer Nature, 2022
Publish Date: 2023-02-01


Background: Healthcare costs are rising, and a substantial proportion of medical care is of little value. De-implementation of low-value practices is important for improving overall health outcomes and reducing costs. We aimed to identify and synthesize randomized controlled trials (RCTs) on de-implementation interventions and to provide guidance to improve future research.

Methods: MEDLINE and Scopus up to May 24, 2021, for individual and cluster RCTs comparing de-implementation interventions to usual care, another intervention, or placebo. We applied independent duplicate assessment of eligibility, study characteristics, outcomes, intervention categories, implementation theories, and risk of bias.

Results: Of the 227 eligible trials, 145 (64%) were cluster randomized trials (median 24 clusters; median follow-up time 305 days), and 82 (36%) were individually randomized trials (median follow-up time 274 days). Of the trials, 118 (52%) were published after 2010, 149 (66%) were conducted in a primary care setting, 163 (72%) aimed to reduce the use of drug treatment, 194 (85%) measured the total volume of care, and 64 (28%) low-value care use as outcomes. Of the trials, 48 (21%) described a theoretical basis for the intervention, and 40 (18%) had the study tailored by context-specific factors. Of the de-implementation interventions, 193 (85%) were targeted at physicians, 115 (51%) tested educational sessions, and 152 (67%) multicomponent interventions. Missing data led to high risk of bias in 137 (60%) trials, followed by baseline imbalances in 99 (44%), and deficiencies in allocation concealment in 56 (25%).

Conclusions: De-implementation trials were mainly conducted in primary care and typically aimed to reduce low-value drug treatments. Limitations of current de-implementation research may have led to unreliable effect estimates and decreased clinical applicability of studied de-implementation strategies. We identified potential research gaps, including de-implementation in secondary and tertiary care settings, and interventions targeted at other than physicians. Future trials could be improved by favoring simpler intervention designs, better control of potential confounders, larger number of clusters in cluster trials, considering context-specific factors when planning the intervention (tailoring), and using a theoretical basis in intervention design.

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Series: Implementation science
ISSN: 1748-5908
ISSN-E: 1748-5908
ISSN-L: 1748-5908
Volume: 17
Article number: 65
DOI: 10.1186/s13012-022-01238-z
Type of Publication: A2 Review article in a scientific journal
Field of Science: 3141 Health care science
Funding: This research was funded by the Strategic Research Council (SRC), which is associated with the Academy of Finland (funding decision numbers 335288, 335288, 336281), and the Sigrid Jusélius Foundation.
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