De-Implementierung von medizinischen Leistungen mit geringem Wert für die Patient*innen aus einer Systemperspektive: Unangemessene Antipsychotika-Verschreibung und Einsatz von Urinkathetern bei älteren Patient*innen als Beispiele

Applying a multi-level perspective to develop de-implementation strategies for inappropriate antipsychotic use and urinary tract catheter use in geriatric patients as examples of low value care practices Low value care (LVC) is an important financial and ethical problem especially in developed countries. LVC are health care practices that provide minimal or no health benefit to the patient. However, current awareness raising campaigns such as Choosing Wisely and research-led initiatives had only limited effects in achieving reduction of LVC practices. This may be due to the inadequate consideration of relevant multi-level determinants in de-implementation efforts. Implementation science can support the de-implementation efforts in at least two ways: 1) offering a systematic process of designing implementation efforts and 2) highlighting the importance of investigating barriers and facilitators of the intervention to select adequate implementation strategies. Currently, little is known on the effectiveness of de-implementation strategies as well as on how de-implementation of LVC practices is planned and executed. The proposed project has three aims: First, we aim to assess the effectiveness of de-implementation strategies applied in different health areas in relation to LVC practice, setting, and stakeholders addressed. Second, we will investigate how de-implementation endeavours are planned and carried out. Third, we aim to select and tailor de-implementation strategies for inappropriate antipsychotic use and urinary tract catheter use in geriatric patients as examples of LVC. To achieve the first aim, we will conduct an overview of systematic reviews on de-implementation studies in selected health areas (e.g., reduction of inappropriate antibiotic use or inappropriate lab tests) and settings (WP 1). In WP 2, we will conduct qualitative systematic reviews on barriers and facilitators regarding the de-implementation of inappropriate antipsychotic medication and urinary tract catheter use in geriatric patients. Furthermore, we will conduct systematic reviews on the effectiveness of de-implementation strategies to tackle inappropriate use of these two health care practices. We will assess the included de-implementation trials in our systematic reviews and conduct online surveys with the study authors to receive a detailed account on the development of the de-implementation strategies. In WP 3, we will apply focus groups and interviews to investigate determinants on multiple levels for the de-implementation of inappropriate antipsychotic prescriptions in patients with dementia and on the inappropriate use of urinary tract catheters in geriatric patients. The results from all WPs will inform the development of congruent de-implementation strategies relevant for these two health care practices. This project will provide a major contribution to our current understanding of how LCV can successfully and sustainably be reduced. It will first elucidate the application of de-implementation strategies in diverse health areas, and second illuminate the process of how de-implementation trials are planned and carried out. The project will also have an impact on clinical practice as we will identify congruent de-implementation strategies for inappropriate antipsychotic prescriptions in patients with dementia and on the inappropriate use of urinary tract catheters in geriatric patients.