Implementation and de-implementation: two sides of the same coin?
Implementation and de-implementation: two sides of the same coin?
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DOI：
10.1136/bmjqs-2016-005473
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发表时间：
2017-06-01
影响因子：
5.4
通讯作者：
Marang-van de Mheen, Perla J.
中科院分区：
文献类型：
--
作者：
van Bodegom-Vos, Leti;Davidoff, Frank;Marang-van de Mheen, Perla J.
在许多国家，避免低价值护理受到越来越多的关注，如明智选择运动和其他放弃浪费资源或对患者没有好处的护理的倡议。虽然大量文献描述了实施循证护理的方法，但我们对取消实施过程的理解有限，例如放弃现有的低价值实践。为了更多地了解实施和取消实施之间的差异，我们探索了文献，并分析了来自同一骨科医生的两项已发表研究（一项实施和一项取消实施）的数据。我们将“领导者”定义为实施或取消实施目标护理流程的骨科医生，将落后者定义为未实施目标护理流程的骨科医生。我们的研究结果表明，领导者在执行和领导者在去执行时，与落后者相比，有一些共同的特点，如更开放的新证据，年轻，在临床实践中的时间更少。然而，解除执行和执行的领导人在其他一些特征上有所不同，不是同一个人。因此，带头执行或不执行可能在某种程度上取决于干预的类型，而不是完全反映个人特点。去执行似乎受到阻碍的动机因素，如部门的优先事项，以及经济和政治因素，如成本效益的考虑，在医疗服务，而组织因素只与实施。实施和取消实施的唯一共同障碍或促进因素包括预期结果（即，感知到的患者净获益）。未来的研究需要测试本研究产生的假设，并提高我们对最有可能领导（或抵制）这些努力的人的实施和去实施过程之间差异的理解。
Avoiding low value care received increasing attention in many countries, as with the Choosing Wisely campaign and other initiatives to abandon care that wastes resources or delivers no benefit to patients. While an extensive literature characterises approaches to implementing evidence-based care, we have limited understanding of the process of de-implementation, such as abandoning existing low value practices. To learn more about the differences between implementation and de-implementation, we explored the literature and analysed data from two published studies (one implementation and one de-implementation) by the same orthopaedic surgeons. We defined `leaders' as those orthopaedic surgeons who implemented, or de-implemented, the target processes of care and laggards as those who did not. Our findings suggest that leaders in implementation share some characteristics with leaders in de-implementation when comparing them with laggards, such as more open to new evidence, younger and less time in clinical practice. However, leaders in de-implementation and implementation differed in some other characteristics and were not the same persons. Thus, leading in implementation or de-implementation may depend to some degree on the type of intervention rather than entirely reflecting personal characteristics. De-implementation seemed to be hampered by motivational factors such as department priorities, and economic and political factors such as cost-benefit considerations in care delivery, whereas organisational factors were associated only with implementation. The only barrier or facilitator common to both implementation and de-implementation consisted of outcome expectancy (ie, the perceived net benefit to patients). Future studies need to test the hypotheses generated from this study and improve our understanding of differences between the processes of implementation and de-implementation in the people who are most likely to lead (or resist) these efforts.