De-implementation Strategies Research Articles

Effectiveness of professional and patient-oriented strategies in reducing vitamin D and B12 test ordering in primary care: a cluster randomised intervention study.

BackgroundVitamin tests are increasingly ordered by GPs, but a clinical and evidence-based indication is often lacking. Harnessing technology (that is, decision support tools and redesigning request forms) have been shown to reduce vitamin requests.AimTo investigate whether the number of vitamin tests may be reduced by providing a multi-level intervention programme based on training, monitoring, and feedback.Design & settingThis was a cluster randomised intervention study performed in 26 primary care health centres (>195 000 patients) in the Netherlands. The relative reduction in ordered vitamin D and B12 tests was determined after introduction of two de-implementation strategies (1 May 2017 to 30 April 2018).MethodHealth centres randomised to de-implementation strategy 1 received education and benchmarking of their own vitamin test ordering behaviour every 3 months. Health centres in de-implementation strategy 2 received the same education and benchmarking, but supplemented with educational material for patients.ResultsThe number of vitamin D tests decreased by 23% compared to the 1-year pre-intervention period (1 May 2016 to 30 April 2017). For vitamin B12 tests an overall reduction of 20% was found. Provision of patient educational information showed additional value over training and benchmarking of GPs alone for vitamin D test ordering (10% extra reduction, odds ratio [OR] 0.88, 95% confidence interval [CI] = 0.83 to 0.92), but not for vitamin B12 ordering (4% extra reduction, OR 0.96, 95% CI = 0.91 to 1.02). Nationwide, this would result in over €3 200 000 in savings on healthcare expenditure a year.ConclusionA structured intervention programme, including training and benchmarking of GPs regarding their diagnostic test ordering, resulted in a significant reduction in ordered vitamin tests. Additional information provision to patients resulted in a small but still relevant additional reduction. If implemented on a national level, a substantial cost saving could be achieved.

Reducing Low-Value Practices a Functional-Contextual Consideration to Aid in De-Implementation Efforts

Through innovation in research and self-correction, it is inevitable that some practices will be replaced or be discredited for one reason or another. De-implementation of discredited and low-value practices is a necessary step for school psychologists’ maintenance of evidence-based practices and to reduce unnecessary costs and risk. However, efforts to clarify de-implementation frameworks and strategies are ongoing. The scope of this paper follows McKay et al. in considering the potential for de-implementation strategies to be informed by applied behavior analysis and operant learning theory. We conceptualize low-value practice as sets of behaviors evoked by their context and maintained by their consequences, and thus de-implementation as behavior reduction. We discuss the need for future research given this perspective.

Is less more? The association between hospital volume and low-value breast cancer surgeries.

68 Background: Hospital volume is often equated with surgical quality. In breast surgical oncology, higher hospital volume has been associated with higher overall survival rates, but whether it is a proxy for quality with respect to low-value care remains unexplored. We thus examined the association between hospital volume and the use of three breast surgeries identified as low-value by the Choosing Wisely campaign. Methods: Patients with stage 0-III unilateral breast cancer diagnosed from 2013-2016 were identified in the National Cancer Database. The outcomes of interest were: 1) contralateral prophylactic mastectomy (CPM), 2) axillary lymph node dissection (ALND) for breast conserving therapy (BCT) patients with cT1-2N0 disease and <2 positive nodes, and 3) sentinel lymph node biopsy (SLNB) in women >70 years old with cT1N0 hormone receptor-positive (HR+) cancer. Multivariable regression models with restricted cubic splines were used to examine the association between annual hospital volume and outcomes of interest, after adjusting for patient-, disease-, and hospital-level risk factors. Results: Overall, 13.6% of 841,610 women with unilateral Stage I-III breast cancer underwent CPM, 9.2% of 832,205 BCT patients with clinical T1-T2N0 disease underwent ALND, and 85.7% of women >70 years of age with cT1N0 HR+ cancer underwent SLNB over the study period. In adjusted analyses that defined hospital volume by decile, patients treated in the first and tenth decile hospitals had lower odds of undergoing CPM as compared to those treated in the middle deciles (Table). BCT patients with cT1-2N0 disease treated in hospitals in the first and second decile had higher odds of undergoing an ALND than patients treated at higher volume hospitals. Hospital volume did not have an overall significant association with SLNB use in women >70 years old with cT1N0 HR+ disease. Conclusions: The relationship between hospital volume and performance of low-value breast surgeries differed for each Choosing Wisely recommendation, indicating that hospital volume is not a reliable proxy for quality with respect to low-value practices. Additional studies to identify practice-specific deimplementation strategies are needed. [Table: see text]

Barriers and facilitators to reduce low-value care: a qualitative evidence synthesis

ObjectiveTo assess barriers and facilitators to de-implementation.DesignA qualitative evidence synthesis with a framework analysis.Data sourcesMedline, Embase, Cochrane Library and Rx for Change databases until September 2018 were searched.Eligibility criteriaWe included...

Trends in Breast Cancer Treatment De-Implementation in Older Patients with Hormone Receptor-Positive Breast Cancer: A Mixed Methods Study.

Guidelines allow for the omission of sentinel lymph node biopsy (SLNB) and post-lumpectomy radiotherapy in women ≥ 70years of age with hormone receptor-positive (HR +) breast cancer. Despite this, national data suggest these procedures have not been widely de-implemented. Our objectives were to evaluate trends in SLNB and post-lumpectomy radiotherapy utilization in patients who are eligible for omission, and evaluate patient preferences as a target for de-implementation of low-value care. We performed a sequential explanatory mixed-methods study by first analyzing an institutional database of patients ≥ 70years of age with HR + breast cancer who received surgical treatment from 2014 to 2018. Based on the quantitative data, we conducted semi-structured interviews with women identified as high or low utilizers of breast cancer treatments to elicit patient perspectives on de-implementation. SLNB and post-lumpectomy radiotherapy were performed in 68% and 43% of patients, respectively, who met the criteria for omission. There was a significant decrease in SLNB rates from 2014 to 2018. Forty-nine percent of patients were classified as high utilizers and 26% were classified as low utilizers. Qualitative analysis found that the most important factors influencing decision making regarding SLNB and post-lumpectomy radiotherapy omission for both high and low utilizers were trust in their provider and a desire for peace of mind. Despite efforts to de-implement low-value care, older women with HR + breast cancer remain at risk of overtreatment. Patient perspectives suggest that multi-level de-implementation strategies will need to target provider practice patterns and patient-provider communication to promote high-quality decision making and reduction in breast cancer overtreatment.

End of an era for erythropoiesis-stimulating agents in oncology.

Erythropoiesis-stimulating agents (ESAs) are available to treat chemotherapy-induced anemia (CIA). In 2007-2008, regulatory notifications advised of venous thromboembolism and mortality risks while the Center for Medicare and Medicaid Services' restricted ESA initiation to patients with hemoglobin <10 g/dl. In 2010, a Risk Evaluation and Mitigation Strategies required consent prior to administration. We evaluated ESA utilization from 2003 to 2012 and obtained private health insurer claims data for persons with lung, colorectal, or breast cancer from 2001 to 2012. ESA use for CIA was determined by an ESA claim after chemotherapy, up to 6 months after treatment. We identified 839,948 commercially insured patients, including 24,785 patients with ESA-treated CIA (3.2%). Darbepoetin use increased 3.9-fold from 2003 to 2007 (12.3% to 48.7%) and then decreased 95% to 2.6% by 2012. Epoetin use decreased 90% from 2003 to 2012 (30.3% to 3.1%). Between 2003 and 2012, mean epoetin dosing decreased 0.8-fold (244,979 in 2003 vs. 196,216 units in 2012), but increased 1.8-fold for darbepoetin-treated CIA (262 in 2003 to 467 μg in 2012). Among CIA patients, transfusions were low (4.5%) in 2002-2007, then increased 2.2-fold between 2008 and 2012. Safety initiatives between 2007 and 2010 facilitated reductions in ESA use combined with changes in coverage. These data show the efficacy of regulatory efforts, publication of adverse events and changes in reimbursement in reducing use of ESAs. Future studies are warranted to optimize deimplementation strategies to improve patient safety.

Addressing low-value pharmacological prescribing in primary prevention of CVD through a structured evidence-based and theory-informed process for the design and testing of de-implementation strategies: the DE-imFAR study

BackgroundDe-implementation or abandonment of ineffective or low-value healthcare is becoming a priority research field globally due to the growing empirical evidence of the high prevalence of such care and its impact in terms of patient safety and social inefficiency. Little is known, however, about the factors, barriers, and facilitators involved or about interventions that are effective in promoting and accelerating the de-implementation of low-value healthcare. The De-imFAR study seeks to carry out a structured, evidence-based, and theory-informed process involving the main stakeholders (clinicians, managers, patients, and researchers) for the design, deployment, and assessment of de-implementation strategies for reducing low-value pharmacological prescribing.MethodsA phase I formative study using a systematic and comprehensive framework based on theory and evidence for the design of implementation strategies—specifically, the Behavior Change Wheel (BCW)—will be conducted to design and model de-implementation strategies to favor reductions in low-value pharmacological prescribing of statins in primary prevention of cardiovascular disease (CVD) by main stakeholders (clinicians, managers, patients, and researchers) in a collegiate way. Subsequently, a phase II comparative hybrid trial will be conducted to assess the feasibility and potential effectiveness of at least one active de-implementation strategy to reduce low-value pharmacological prescribing of statins in primary prevention of CVD compared to the usual procedures for dissemination of clinical practice guidelines (“what-not-to-do” recommendations). A mixed-methods evaluation will be used: quantitative for the results of the implementation at the professional level (e.g., adoption, reach and implementation or execution of the recommended clinical practice); and qualitative to determine the feasibility and perceived impact of the de-implementation strategies from the clinicians’ perspective, and patients’ experiences related to the clinical care received.DiscussionThe DE-imFAR study aims to generate valid scientific knowledge about the design and development of de-implementation strategies using theory- and evidence-based methodologies suggested by implementation science. It will explore the effectiveness of these strategies and their acceptability among clinicians, policymakers, and patients. Its ultimate goal is to maximize the quality and efficiency of our health system by abandoning low-value pharmacological prescribing.Trial registrationClinicaltrials.gov identifier: NCT04022850. Registered 17 July 2019

Factors Influencing Primary Care Providers\u2019 Unneeded Lumbar Spine MRI Orders for Acute, Uncomplicated Low-Back Pain: a Qualitative Study

BackgroundClinical practice guidelines suggest that magnetic resonance imaging of the lumbar spine (LS-MRI) is unneeded during the first 6 weeks of acute, uncomplicated low-back pain. Unneeded LS-MRIs do not improve patient outcomes, lead to unnecessary surgeries and procedures, and cost the US healthcare system about $300 million dollars per year. However, why primary care providers (PCPs) order unneeded LS-MRI for acute, uncomplicated low-back pain is poorly understood.ObjectiveTo characterize and explain the factors contributing to PCPs ordering unneeded LS-MRI for acute, uncomplicated low-back pain.DesignQualitative study using semi-structured interviews.ParticipantsVeterans Affairs PCPs identified from administrative data as having high or low rates of guideline-concordant LS-MRI ordering in 2016.ApproachProviders were interviewed about their use of LS-MRI for acute, uncomplicated low-back pain and factors contributing to their decision-making. Directed content analysis of transcripts was conducted to identify and compare environmental-, patient-, and provider-level factors contributing to unneeded LS-MRI.Key ResultsFifty-five PCPs participated (8.6% response rate). Both low (n = 33) and high (n = 22) guideline-concordant providers reported that LS-MRIs were required for specialty care referrals, but they differed in how other environmental factors (stringency of radiology utilization review, management of patient travel burden, and time constraints) contributed to LS-MRI ordering patterns. Low- and high-guideline-concordant providers reported similar patient factors (beliefs in value of imaging and pressure on providers). However, provider groups differed in how provider-level factors (guideline familiarity and agreement, the extent to which they acquiesced to patients, and belief in the value of LS-MRI) contributed to LS-MRI ordering patterns.ConclusionsResults describe how diverse environmental, patient, and provider factors contribute to unneeded LS-MRI for acute, uncomplicated low-back pain. Prior research using a single intervention to reduce unneeded LS-MRI has been ineffective. Results suggest that multifaceted de-implementation strategies may be required to reduce unneeded LS-MRI.

1053. De-Implementing Low-Value Antibiotic Prescribing Across Levels of Care

BackgroundPerforming urinalyses and urine cultures in asymptomatic patients is one of the most common reasons for inappropriate antibiotic use. However, de-implementing this practice has been difficult, especially for clinical scenarios deemed to be high risk for infectious complications, such as among patients with delirium or those undergoing orthopedic implant surgery.MethodsUsing the dual-process theory framework “Developing De-Implementation Strategies Based on Un-Learning and Substitution,” an educational intervention citing new IDSA guidelines and providing a pneumonic “ABCs of ASB” was created and delivered didactically to providers. The goal was to increase performance of evidence-based prevention actions in place of low-value urine screening and treating of asymptomatic patients. Clinical providers and staff (MD, RN, APRN, trainees) in 3 different levels of care (acute inpatient, long-term, and outpatient) were included. A web-based anonymous and confidential pre- and post-question format was delivered to assess influence on provider behavior.ResultsResponses from a range of 250–279 unique providers were collected. For scenario #1 (patient with delirium and a positive urine culture and no other infectious symptoms), the option to give antibiotics was reduced by 45% pre to 4% post, Chi-square P < 0.01). For scenario #2 (patient having a knee replacement and positive preoperative urine culture, no other symptoms) the option to give antibiotics was reduced by the same magnitude (~50%) but a lower absolute number (67% pre and 33% post, chi-square P < 0.01). Changes in predicted behavior were similar across levels of care.ConclusionSubstituting evidence-based practices in place of low-value practices is an appealing framework for influencing provider behavior. Our work demonstrates that education can successfully reduce the intention to use antibiotics for asymptomatic patients with positive urine cultures.Disclosures All authors: No reported disclosures.

Reducing unnecessary vitamin testing in general practice: barriers and facilitators according to general practitioners and patients

ObjectiveThere has been an increase in testing of vitamins in patients in general practice, often based on irrational indications or for non-specific symptoms, causing increasing healthcare expenditures and medicalisation of...

Promoting Health Equity through De-Implementation Research.

Ensuring equitable access to quality health care historically has focused on gaps in care, where patients fail to receive the high-value care that will benefit them, something termed underuse. But providing high-quality health care sometimes requires reducing low-value care that delivers no benefit or where known harms outweigh expected benefits. These situations represent health care overuse. The process involved in reducing low-value care is known as de-implementation. In this article, we argue that de-implementation is critical for advancing equity for several reasons. First, medical overuse is associated with patient race, ethnicity, and socioeconomic status. In some cases, the result is even double jeopardy, where racial and ethnic minorities are at higher risk of both overuse and underuse. In these cases, more traditional efforts focused exclusively on underuse ignore half of the problem. Second, overuse of preventive care and screening is often greater for more socioeconomically advantaged patients. Within insured populations, this means more socioeconomically disadvantaged patients subsidize overuse. Finally, racial and ethnic minorities may have different experiences of overuse than Whites in the United States. This may make efforts to de-implement overuse particularly fraught. We therefore provide several actions for closing current research gaps, including: adding subgroup analyses in studies of medical overuse; specifying and measuring potential mechanisms related to equity (eg, double jeopardy vs thermostat models of overuse); and testing de-implementation strategies that may mitigate bias.

Promoting Health Equity through De-Implementation Research

Ensuring equitable access to quality health care historically has focused on gaps in care, where patients fail to receive the high-value care that will benefit them, something termed unde­ruse. But providing high-quality health care sometimes requires reducing low-value care that delivers no benefit or where known harms outweigh expected benefits. These situations represent health care overuse. The process involved in reducing low-value care is known as de-implementation. In this article, we argue that de-implementation is critical for advanc­ing equity for several reasons. First, medical overuse is associated with patient race, ethnic­ity, and socioeconomic status. In some cases, the result is even double jeopardy, where racial and ethnic minorities are at higher risk of both overuse and underuse. In these cases, more tra­ditional efforts focused exclusively on underuse ignore half of the problem. Second, overuse of preventive care and screening is often greater for more socioeconomically advantaged pa­tients. Within insured populations, this means more socioeconomically disadvantaged pa­tients subsidize overuse. Finally, racial and eth­nic minorities may have different experiences of overuse than Whites in the United States. This may make efforts to de-implement over­use particularly fraught. We therefore provide several actions for closing current research gaps, including: adding subgroup analyses in studies of medical overuse; specifying and measuring potential mechanisms related to equity (eg, double jeopardy vs thermostat models of over­use); and testing de-implementation strategies that may mitigate bias.Ethn Dis. 2019;29(Suppl 1):93-96; doi:10.18865/ed.29.S1.93.

Deimplementation of Routine Chest X-rays in Adult Intensive Care Units.

Choosing Wisely® is a national initiative to deimplement or reduce low-value care. However, there is limited evidence on the effectiveness of strategies to influence ordering patterns. We aimed to describe the effectiveness of an intervention to reduce daily chest X-ray (CXR) ordering in two intensive care units (ICUs) and evaluate deimplementation strategies. We aimed to describe the effectiveness of an intervention to reduce daily chest X-ray (CXR) ordering in two intensive care units (ICUs) and evaluate deimplementation strategies. The study was performed in the medical intensive care unit (MICU) and cardiovascular intensive care unit (CVICU) of an academic medical center in the United States from October 2015 to June 2016. The initiative included the staff of the MICU and CVICU (physicians, surgeons, nurse practitioners, fellows, residents, medical students, and X-ray technologists). We utilized provider education, peer champions, and weekly data feedback of CXR ordering rates. We analyzed the CXR ordering rates and factors facilitating or inhibiting deimplementation. Segmented linear time-series analysis suggested a small but statistically significant decrease in CXR ordering rates in the CVICU (P < .001) but not in the MICU. Facilitators of deimplementation, which were more prominent in the CVICU, included engagement of peer champions, stable staffing, and regular data feedback. Barriers included the need to establish goal CXR ordering rates, insufficient intervention visibility, and waning investment among medical residents in the MICU due to frequent rotation and competing priorities. Intervention modestly reduced CXRs ordered in one of two ICUs evaluated. Understanding why adoption differed between the two units may inform future interventions to deimplement low-value diagnostic tests.

De-implementation of tradition-based practices in critical care: A qualitative study.

To explore the process of tradition-based practice (TBP) de-implementation by critical care nurses. Ritualistic and routine practices have been described as sacred cows or TBPs. Many clinical practices have insufficient or no evidence and may lead to poor patient outcomes. De-implementation (termination) of potentially harmful, ineffective, or non cost-effective TBP is necessary to facilitate evidence-based practice (EBP) in the clinical setting. Descriptive qualitative inquiry guided this study. Twenty-two critical care nurses from an acute care hospital in central Florida participated. Individual and focus group interviews were performed March to July 2016 and analysed using thematic analysis. Three themes were identified: (a) uncertainty, (b) desire to know, and (c) preparing for practice change. Nurses were uncertain about the scientific underpinnings of everyday clinical practices and had difficulty differentiating TBP from EBP. De-implementation processes and strategies appeared to replicate implementation processes. More research is needed to evaluate de-implementation processes and strategies used for de-implementation. An emphasis should be placed on ensuring that nurses are knowledgeable about fundamental EBP skills to encourage assessment of clinical practices for supporting research evidence. Awareness and understanding of TBPs will facilitate a more comprehensive approach towards achieving the gold standard of EBP.

De-implementation of low value castration for men with prostate cancer: protocol for a theory-based, mixed methods approach to minimizing low value androgen deprivation therapy (DeADT)

BackgroundMen with prostate cancer are often castrated with long-acting injectable drugs termed androgen deprivation therapy (ADT). Although many benefit, ADT is also used in patients with little or nothing to gain. The best ways to stop this practice are unknown, and range from blunt pharmacy restrictions to informed decision-making. This study will refine and pilot two different de-implementation strategies for reducing ADT use among those unlikely to benefit in preparation for a comparative effectiveness trial.Methods/designThis innovative mixed methods research program has three aims. Aim 1: To assess preferences and barriers for de-implementation of chemical castration in prostate cancer. Guided by the theoretical domains framework (TDF), urologists and patients from facilities with the highest and lowest castration rates across the VA will be interviewed to identify key preferences and de-implementation barriers for reducing castration as prostate cancer treatment. This qualitative work will inform Aim 2 while gathering rich information for two proposed pilot intervention strategies. Aim 2: To use a discrete choice experiment (DCE), a novel barrier prioritization approach, for de-implementation strategy tailoring. The investigators will conduct national surveys of urologists to prioritize key barriers identified in Aim 1 for stopping incident castration as localized prostate cancer treatment using a DCE experiment design. These quantitative results will identify the most important barriers to be addressed through tailoring of two pilot de-implementation strategies in preparation for Aim 3 piloting. Aim 3: To pilot two tailored de-implementation strategies to reduce castration as localized prostate cancer treatment. Building on findings from Aims 1 and 2, two de-implementation strategies will be piloted. One strategy will focus on formulary restriction at the organizational level and the other on physician/patient informed decision-making at different facilities. Outcomes will include acceptability, feasibility, and scalability in preparation for an effectiveness trial comparing these two widely varying de-implementation strategies.DiscussionOur innovative approach to de-implementation strategy development is directly aligned with state-of-the-art complex implementation intervention development and implementation science. This work will broadly advance de-implementation science for low value cancer care, and foster participation in our de-implementation evaluation trial by addressing barriers, facilitators, and concerns through pilot tailoring.Trial registrationClinicalTrials.gov Identifier: NCT03579680, First Posted July 6, 2018.

How the dual process model of human cognition can inform efforts to de-implement ineffective and harmful clinical practices: A preliminary model of unlearning and substitution.

Rationale and objectivesOne way to understand medical overuse at the clinician level is in terms of clinical decision‐making processes that are normally adaptive but become maladaptive. In psychology, dual process models of cognition propose 2 decision‐making processes. Reflective cognition is a conscious process of evaluating options based on some combination of utility, risk, capabilities, and/or social influences. Automatic cognition is a largely unconscious process occurring in response to environmental or emotive cues based on previously learned, ingrained heuristics. De‐implementation strategies directed at clinicians may be conceptualized as corresponding to cognition: (1) a process of unlearning based on reflective cognition and (2) a process of substitution based on automatic cognition.ResultsWe define unlearning as a process in which clinicians consciously change their knowledge, beliefs, and intentions about an ineffective practice and alter their behaviour accordingly. Unlearning has been described as “the questioning of established knowledge, habits, beliefs and assumptions as a prerequisite to identifying inappropriate or obsolete knowledge underpinning and/or embedded in existing practices and routines.” We hypothesize that as an unintended consequence of unlearning strategies clinicians may experience “reactance,” ie, feel their professional prerogative is being violated and, consequently, increase their commitment to the ineffective practice.We define substitution as replacing the ineffective practice with one or more alternatives. A substitute is a specific alternative action or decision that either precludes the ineffective practice or makes it less likely to occur.Both approaches may work independently, eg, a substitute could displace an ineffective practice without changing clinicians' knowledge, and unlearning could occur even if no alternative exists. For some clinical practice, unlearning and substitution strategies may be most effectively used together.ConclusionsBy taking into account the dual process model of cognition, we may be able to design de‐implementation strategies matched to clinicians' decision‐making processes and avoid unintended consequence.

The relationship between consumer, clinician, and organizational characteristics and use of evidence-based and non-evidence-based therapy strategies in a public mental health system

We investigated the relationship between consumer, clinician, and organizational factors and clinician use of therapy strategies within a system-wide effort to increase the use of cognitive-behavioral therapy. Data from 247 clinicians in 28 child-serving organizations were collected. Clinicians participating in evidence-based practice training initiatives were more likely to report using cognitive-behavioral therapy when they endorsed more clinical experience, being salaried clinicians, and more openness to evidence-based practice. Clinicians participating in evidence-based practice initiatives were more likely to use psychodynamic techniques when they had older clients, less knowledge about evidence-based practice, more divergent attitudes toward EBP, higher financial strain, and worked in larger organizations. In clinicians not participating in evidence-based training initiatives; depersonalization was associated with higher use of cognitive-behavioral; whereas clinicians with less knowledge of evidence-based practices were more likely to use psychodynamic techniques. This study suggests that clinician characteristics are important when implementing evidence-based practices; and that consumer, clinician, and organizational characteristics are important when de-implementing non evidence-based practices. This work posits potential characteristics at multiple levels to target with implementation and deimplementation strategies.

Designing a strategy to implement cost-effective blood transfusion management in elective hip and knee arthroplasties: A study protocol

BackgroundTotal hip and knee arthroplasties are two of the most commonly performed procedures in orthopedic surgery. Different blood-saving measures (BSMs) are used to reduce the often-needed allogenic blood transfusions in these procedures. A recent large randomized controlled trial showed it is not cost effective to use the BSMs of erythropoietin and perioperative autologous blood salvage in elective primary hip and knee arthroplasties. Despite dissemination of these study results, medical professionals keep using these BSMs. To actually change practice, an implementation strategy is needed that is based on a good understanding of target groups and settings and the psychological constructs that predict behavior of medical professionals. However, detailed insight into these issuses is lacking. Therefore, this study aims to explore which groups of professionals should be targeted at which settings, as well as relevant barriers and facilitators that should be taken into acount in the strategy to implement evidence-based, cost-effective blood transfusion management and to de-implement BSMs.MethodsThe study consists of three phases. First, a questionnaire survey among all Dutch orthopedic hospital departments and independent treatment centers (n = 99) will be conducted to analyze current blood management practice. Second, semistructured interviews will be held among 10 orthopedic surgeons and 10 anesthesiologists to identify barriers and facilitators that are relevant for the uptake of cost-effective blood transfusion management. Interview questions will be based on the Theoretical Domains Interview framework. The interviews will be followed by a questionnaire survey among 800 medical professionals in orthopedics and anesthesiology (400 professionals per discipline) in which the identified barriers and facilitators will be ranked by frequency and importance. Finally, an implementation strategy will be developed based on the results from the previous phases, using principles of intervention mapping and an expert panel.DiscussionThe developed strategy for cost-effective blood transfusion management by de-implementing BSMs is likely to reduce costs for elective hip and knee arthroplasties. In addition, this study will lead to generalized knowledge regarding relevant factors for the de-implementation of non-cost-effective interventions and insight in the differences between implementation and de-implementation strategies.