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Connecting Overuse and Implementation Research

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In August, I was fortunate to attend the 5th Annual Preventing Overdiagnosis Conference (PODC) in Quebec City, Canada. The PODC is an annual conference of approximately 300 international attendees focused on describing, understanding, and reducing overscreening, overdiagnosis, and overtreatment (‘overuse’) of health care practices, services, and innovations across many health areas (e.g., cancer, heart disease) and delivery settings (e.g., hospitals, clinics). This year’s theme, Towards Responsible Global Solutions, reflected the field’s movement toward preventing, reducing, and stopping overuse. The conference had an all-star group of speakers reflecting research, practice, and policy spheres, including Barnett Kramer, France Légaré, Wendy Levinson, André Picard, Vinay Prasad, and Rita Redberg. This is one of my favorite conferences; attendees are a mix of researchers, practitioners, public policymakers, patient advocates, health reporters, professional societies, and others, reflecting the various stakeholder groups interested in better understanding, preventing, and reducing overuse.

Overuse of health services, practices, and innovations is increasingly recognized as a substantial problem in health care, contributing to inefficient use of resources, higher costs, and direct and indirect harm to patients (e.g., stress, financial strain, side effects, toxicity, anxiety, and pain). Implementation research is well positioned to be an important collaborating discipline in reducing or stopping overuse of inappropriate, harmful, or unproven health services, practices, and innovations. Indeed, it is likely that many of the contextual and multi-level factors contributing to or promulgating overuse are the same factors as those related to implementing evidence-based services, practices, and innovations, albeit working through different mechanisms and varying in intensity. For example, we know from a substantial body of empirical research that, in most cases, information is necessary but insufficient to lead to behavior change. Thus, interventions focused solely on informing clinicians of guidelines to adopt evidence-based practices have overwhelmingly failed to lead to significant and sustained behavior change (i.e., adoption of such practices). Similarly, one may hypothesize that the sole provision of information about overuse may be necessary but unlikely to lead to significant and sustained behavior change (i.e., reduce or stop use of such practices) without pulling additional levers of change (e.g., role playing, motivation, opinion leaders, etc.). In these ways, implementation research has much to contribute to understanding and testing strategies for reducing or stopping the overuse of inappropriate, harmful, or unproven health services, practices, and innovations. We can build on the evidence base in implementation and apply it to the problem of overuse.

While lessons learned from implementation research can and should be applied to preventing, reducing, or stopping overuse of inappropriate services, we must also acknowledge that there are likely to be some differences in predictors, processes, and strategies for reducing or stopping overuse. Arguably, too, based on research in social and clinical psychology, reducing or stopping a behavior or set of behaviors—particularly without a change in context—is much more difficult than starting a new one. As a field, we will need to acknowledge this challenge and identify ways in which more strategies with greater intensity and longer duration may be necessary to reduce or stop overuse.

For those who are interested, it is an exciting and opportune time to apply what we know about implementing health services, practices, and innovations to reducing or stopping the use of inappropriate health services, practices, and innovations. Perhaps, too, this will be an opportunity for us to expand our partnerships, extend our thinking, and increase our impact on patient and population health. We would appreciate hearing your thoughts on the potential for advancing research in this important area.

Wynne E. Norton, PhD
wynne.norton@nih.gov

Select readings:
1. Morgan, DJ, Brownlee, S, Leppin, AL, et al. (2015). Setting a research agenda for medical overuse. BMJ, 351. PubMed link: https://www.ncbi.nlm.nih.gov/pubmed/26306661.

2. Montini, T, & Graham, ID. (2014). Entrenched practices and other biases: unpacking the historical, economic, professional, and social resistance to de-implementation. Implementation Science, 10, 24. PubMed link: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4339245/.

3. Prasad, V & Ioannidis, JPA. (2014). Evidence-based de-implementation for contradicted, unproven, and aspiring healthcare practices. Implementation Science, 9, 1. PubMed link: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3892018/.


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