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Helfrich CD. De-implementation of ineffective and harmful clinical practices: Preliminary thoughts on a planned-action model based on unlearning and substitution. Presentation at the Health Promotion Research Center Seminar, University of Washington.. 2016 Sep 8.
We propose a planned action model of de-implementation of medical overuse at the provider level based on the dual process model of human cognition and decision making: System 1 cognition which is automatic, largely unconscious, heuristic-driven, rapid and efficient; and System 2 cognition which is reflective, conscious, logic-driven, slow and inefficient. We propose that de-implementation strategies targeting providers can be characterized as addressing one or both types of cognitions. De-implementation strategies can target system 1 cognition by introducing a substitute practice or substitute heuristic that precludes in the ineffective clinical practice. De-implementation strategies can target system 2 cognition by engaging clinicians in actively unlearning the ineffective clinical practice. Or strategies might incorporate both unlearning and substitution. We illustrate the model with examples of current quality improvement projects to reduce the use of antipsychotics for managing behavioral issues among patients with dementia in nursing homes, and to reduce the use of inhaled corticosteroids to manage breathing exacerbations among patients with mild to moderate chronic obstructive pulmonary disease.