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A Conceptual Framework for Developing De-Implementation Strategies Based on Un-Learning and Substitution.

Helfrich CD, Hartmann CW, Rose AJ, Winchester D, Zeliadt SB, Majerczyk B, Au DH. A Conceptual Framework for Developing De-Implementation Strategies Based on Un-Learning and Substitution. Poster session presented at: AcademyHealth Annual Research Meeting; 2016 Jun 26; Boston, MA.


Research Objective: De-implementation may differ in important ways from implementation, and likely entails greater potential for unintended consequences. The harmful practices we wish to de-implement often have deep historical, economic, political and social roots. As a result, de-implementation efforts might be perceived by patients and especially clinicians as an unwelcome intrusion on their prerogative and a loss of freedom, and might provoke strong resistance or reactance. Most de-implementation strategies to date, such as the Choosing Wisely efforts, are based on making a rational argument for clinician and patient behavior change. However, research from cognitive psychology has demonstrated that people experiencing reactance discount information. We need to understand when de-implementation through conscious behavior change is likely to be effective, and to develop alternative strategies when the threat of reactance is high. Study Design: We propose a planned action model in which de-implementation of ineffective clinical practices results from two distinct, potentially synergistic processes: 1) a process of unlearning; and 2) a process of substitution. Population Studied: Conceptual model. Principal Findings: We define de-implementation as abandoning an existing clinical practice because evidence emerges that the practice is ineffective or harmful, even in the absence of a specific superior alternative. Unlearning is an active process in which clinicians consciously change their knowledge, beliefs and intentions about the ineffective practice, and alter their behavior accordingly. There is a spectrum from simple unlearning, which abandons the ineffective practice fits within existing mental models, to deep unlearning, requiring adopting new mental models. Unlearning strategies are unlikely to work when clinicians perceive a threat to their freedom. Perceived threats to freedom is more likely in cases where the ineffective practice is frequently used, or has a long history of use. Substitution involves the promotion of one or more alternatives to the ineffective practice, in which the substitute practice either precludes the ineffective practice (e.g., watchful waiting for prostate cancer), or makes it less likely to occur (e.g., referring back pain to physical therapy rather than a surgeon). Substitution de-implementation strategies will be more likely to be effective if there is an environmental cue for the clinician to use the substitute practice at the point of decision making. We expect to find that each approach can work independently, that in some situations an unlearning approach will be effective and highly efficient, and that in cases the two approaches may work synergistically. We also expect that attributes of the practice targeted for de-implementation, such as the clinical setting and the clinicians' prior experiences with quality improvement efforts and relationships with organizational leadership, will help determine which approach will work best. Conclusions: This planned-action model proposes two distinct de-implementation processes, unlearning and substitution, each potentially effective for different clinical practices and settings. Implications for Policy or Practice: De-implementation strategies based on unlearning and substitution can be empirically tested and compared to increase our knowledge about which strategies are most effective in which contexts.

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