Two main components drive low-value practices in health care: underuse and overuse. Underuse (eg, undervaccination), although important, has received greater focus historically. However, because of the rising costs of health care in the United States and the realization that we can “safely do less” as pediatricians,1 the equally significant domain of overuse, or the provision of care in which the harms outweigh the benefits,2 is receiving increasing attention. A quality improvement (QI) expert, Dr Don Berwick, recently cited overuse as the “next quality frontier.”3 The field of pediatrics is not exempt from overuse. In a limited review, Chua et al4 demonstrated that 1 in 10 commercially insured children are exposed to low-value practices, with an approximate cost of $27 million per year.

The commonplace nature of low-value care in pediatrics should prompt pediatricians to familiarize themselves with the growing call for “deimplementation” in medicine.5 Deimplementation refers to the science of abandoning and unlearning practices built on the scaffolding of habit. Prasad and Ioannidis,5 both experts in the fields of overuse and evidence-based medicine, classify efforts ripe for deimplementation into 3 categories: practices that are novel but yet not fully tested, unproven practices (those that lack supporting evidence), and practices of habit (practices that continue despite contradictory evidence).

Efforts to reduce unnecessary testing are fruitful deimplementation targets for clinicians because, by their nature, unnecessary tests are low-value interventions that often lead to overtreatment and overdiagnosis and are therefore harmful.6,7 In this issue of Pediatrics, Hiscock et al8 systematically reviewed published deimplementation efforts that aimed to reduce unnecessary pathology and imaging tests. They limited their review to publications with “sustainable solutions,” or those with a follow-up period of at least 6 months. The authors identified 64 articles with a diverse group of interventions, methods, and targets all aimed at reducing unnecessary testing.8 The deimplementation efforts reviewed largely fall into the latter 2 categories described above from Prasad and Ioannidis5: unproven or habitual practices. The authors of this comprehensive and well-designed review identified a variety of themes worth noting for clinicians wishing to undertake similar efforts.

The authors of this review suggest that a multifaceted approach that includes education, audit and/or feedback, and system- and/or process-based interventions is more effective and sustainable than efforts that incorporate only 1 type of intervention. Also, projects with a narrower scope (ie, those that attempted to minimize unnecessary imaging rather than both imaging and pathology testing) proved more effective. Additionally, most of the studies were conducted in single institutions rather than through a multi-institutional approach. Single-site efforts showed greater reductions in testing than multicenter ones. One possible interpretation of this finding may be that institutional culture influenced deimplementation efforts that are often not fully generalizable. However, lessons may be learned by some successful multicenter deimplementation efforts. In particular, those that provide evidence-based practices for participants, build institutional QI capacity, and provide effective team engagement have demonstrated to be both impactful and sustainable.9,10 

Most notably, Hiscock et al8 found that interventions that included both clinicians and families were more effective than those solely targeting clinicians. This underscores the value of a family-centered, shared-decision approach in deimplementation efforts. Yet, engaging patients and families in deimplementation efforts can be daunting. Morgan, an epidemiologist who has studied overuse and ways to implement best practices, and his colleagues11 developed a novel framework with other colleagues to guide family-centered deimplementation efforts. The framework identifies both patient and system drivers that contribute to overuse, including the culture of health care consumption, previous patient experiences, the culture of professional medicine, and ingrained clinician attitudes and beliefs. These then coalesce into a patient-clinician interaction in a practice environment, resulting in a shared health care decision. Morgan et al11 propose that this framework be used to identify opportunities for change and therefore inform interventions aimed at reducing overuse while involving the patients and families.

Hiscock et al8 note that the design of most of the reviewed studies was of lower quality, including only 1 randomized controlled trial. The authors argue that this finding should prompt researchers to choose better methodologies, such as randomized controlled trials or more rigorous QI designs including interrupted time series, in future studies.8 Although it is certainly true that better study designs are preferred for such deimplementation efforts, we must also demand that this higher standard be applied before implementing those interventions that prompted the studies reviewed by Hiscock et al8 in the first place.

For the most part, the interventions identified by Hiscock et al8 targeted practices that lack a basis in evidence and yet are routinely performed. These habitual and unproven practices were seen in a variety of settings. From chest radiographs for asthma and bronchiolitis in the emergency department or inpatient units, to daily chest radiographs and routine laboratories in the pediatric or cardiovascular ICU, Hiscock et al8 also demonstrate the frequency of habitual, unsupported practices. In many cases, these practices may be considered “standard of care.” Too often in medicine, we define standards of care by what we do rather than by what is supported. In pediatrics, doing more is often perceived as better care, and efforts to discuss parsimonious care are far less common despite convincing arguments that it is ethically imperative.12 

However, efforts to deimplement unsupported interventions may be aided by the realization that practices considered standard of care are often reversed when rigorously evaluated. One such review in adults evaluating reversal of “established medical practices” revealed 146 such cases in just 10 years’ worth of data.13 Although a similar study has not been undertaken in pediatrics, the frequency of such cases in adults should give pause to pediatricians when accepting any established practice as standard of care. Thus, although the review by Hiscock et al8 should encourage more rigorous studies, it should also remind us that our own practice should be sufficiently flexible and humble that it enables us to recognize when we are wrong and allows us to choose better.

     
  • QI

    quality improvement

Dr Walker conceptualized this commentary, created the initial draft, and edited; Dr Quinonez conceptualized this commentary and edited; and both authors approved the final draft.

Opinions expressed in these commentaries are those of the authors and not necessarily those of the American Academy of Pediatrics or its Committees.

FUNDING: No external funding.

COMPANION PAPER: A companion to this article can be found online at www.pediatrics.org/cgi/doi/10.1542/peds.2017-2862.

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Competing Interests

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.