The publication dates of the included articles ranged from 1982 to 2021, where half the articles dated after 2010. Most articles were from North America (
n = 18, 36%) and Europe (
n = 16, 32%). The majority of the studies (
n = 41, 82%) were targeted to one type of professionals, and nine studies (18%) reported several target groups. Around two-thirds of the studies (
n = 35, 70%) were conducted in primary care. The trials were aimed at reducing the use of drug treatments (
n = 37, 74%), laboratory test (
n = 8, 16%), or diagnostic imaging (
n = 6, 12%). The studies used 16 different de-implementation strategies. Twenty-six used only one strategy, and twenty-four were multifaceted including two or more strategies. In all studies, the goal was to reduce use of a specific health care intervention. In 14 studies, an additional goal was replacing. The description of the characteristics of the included studies is shown in Table
1, and full characteristics are found in Additional file
5.
Table 1
Characteristics of the de-implementation interventions
Physicians | 35 | 13 | Primary care outpatient | 34 | 13 |
Patients | 2 | | Primary care inpatient and outpatient | 1 | 1 |
Nurses | 2 | 1 | Secondary or tertiary care outpatient | 2 | |
Other health care providers | 2 | | Secondary or tertiary care inpatient | 12 | 3 |
Two or more target groups | 9 | 4 | Nursing home | 1 | 1 |
Medical contenta | N | | Clinical interventiona | N | |
Family/general practice | 36 | 13 | Drug treatment | 37 | 15 |
Mixed, but not specified | 8 | 3 | Antibiotic use | 26 | |
Emergency medicine | 2 | | NSAID use | 3 | |
General surgery | 2 | 1 | Overall prescribing | 2 | |
Orthopedics | 2 | 1 | A combination of different drugs | 6 | |
Anesthesiology | 1 | | Laboratory tests | 8 | |
Internal medicine | 1 | | Diagnostic imaging | 6 | 0 |
Obstetric | 1 | | Blood transfusion | 1 | 1 |
Oncology | 1 | 1 | Prevention | 1 | 1 |
Pediatrics | 1 | | Rehabilitation | 1 | 1 |
Psychiatrics | 1 | 1 | | | |
Pulmonary surgery | 1 | 1 | | | |
Urology | 1 | 1 | | | |
Vascular surgery | 1 | 1 | | | |
Number of used strategies | N | | | | |
1 | 26 | 6 | | | |
2 | 13 | 5 | | | |
3 | 7 | 4 | | | |
4 | 4 | 3 | | | |
De-implementation costs
The total costs of de-implementation intervention were reported in 13 studies (6%). These total costs varied considerably, the median being US $32,300 (range: US $616 to 747,000). Table
3 shows total costs converted to US dollars in 2021 value.
Table 3
De-implementation total costs and costs per unit, converted by the authors to USD 2021 value (on October 25, 2022)
Alexander et al. (1996) [35] | Rehabilitation | 9710b | |
Bexell et al. (1996) [36] | Drug treatment | 6470b | |
Dormuth et al. (2012) [37] | Drug treatment | 118,000b | |
Gulliford et al. (2019) [38] | Drug treatment, AB | 747,000a | |
Hemkens et al. (2017) [39] | Drug treatment | 330,000b | |
| Prevention | 43,600b | |
Ashworth et al. (2021) [41] | Drug treatment | 7071c | 10.2–65.23/doctor |
Butler et al. (2012) [26] | Drug treatment | 163,0001 | 49501/health care unit |
Coenen et al. (2004) [42] | Drug treatment | 6845d | 2804/doctor |
Gulliford et al. 2014) [43] | Drug treatment, AB | 579,000a | 0.461/patient |
| Drug treatment | 616b | 0.672/doctor |
Solomon et al. (2001) [45] | Drug treatment, AB | 32,300b | 32,3002/health care unit |
| Drug treatment, AB | 22,175e | 2845/doctor |
| Drug treatment | | 2322/doctor |
| Drug treatment | | 3.624/patient |
| Drug treatment | | 1962/health care provider |
Soumerai et al. (1993) [28] | Blood transfusion | | 12902/day |
| Drug treatment, AB | | 4122/health care unit |
The 13 studies (26%) that reported total costs used ten different de-implementation strategies. The most common strategies were educational materials (n = 9), audit and feedback (n = 7), educational meetings for individuals (n = 4), treatment algorithm (n = 3), educational meetings for groups (n = 3), and developing clinical practice guidelines (n = 2). The strategies used in one study included alerts, local consensus process, educational material for patients, and public intervention. Strategy combinations were diverse; many combined different educational strategies together. When using educational material in de-implementation, the median for total costs median was US $118,000 (range: US $6845 to 747,000). The total costs seemed higher in studies using educational materials than in studies not using such materials when not using it (Mann–Whitney test, p = 0.05). For other strategies, the total costs did not significantly differ between studies using vs. from not using each strategy (Mann–Whitney test, all p > 0.05).
In studies that used only one de-implementation strategy (n = 4, 31%), the median for total costs was US $8090 (range: US $616 to 32,300). In studies using two de-implementation strategies (n = 2, 15%), the median for total costs was US $224,000 (range: US $118,000 to 330,000), and with three or more strategies (n = 7, 54%), the median for total costs was US $43,600 (range US $6845 to 747,000).
Costs per unit were reported in 12 studies (5%). The most common unit was cost per physician, but also costs per health care provider, health care unit, day, and patient were reported (Table
3). In these studies, various de-implementation strategies were used. The most common were educational materials (
n = 8), educational meetings for individuals (
n = 6), and for groups (
n = 5), audit and feedback (
n = 5), and educational materials for patients (
n = 2). Alerts, treatment algorithms, public intervention, and developing clinical practice guidelines were each used once. There were no differences in costs between using a given strategy and not using it (Mann–Whitney test, all
p > 0.05).
Of the articles that reported total costs or costs per unit, 10 out of 18 (56%) offered at least some detailed information on the costs, but only four (22%) reported the exact costs. The most frequently reported types of costs were material costs, payment for trainers, and travel costs. In addition, postage, rent of premises, and loss of working hours were occasionally reported. Cost related to de-implementation intervention planning was rarely brought out. Information on costing methods was not mentioned in the articles. None of the articles separated costs related to the phases of de-implementation.
A meta-analysis was not possible due to the heterogeneity of the studies (e.g., the type and number of de-implementation strategies used). There were few studies in the pre-specified subgroups, so subgroup analyses were not appropriate.
Impact on health care costs
The impact on health care costs was reported in 43 studies (19%). In most cases, the reports did not specify to whom the impact was targeted (n = 25, 58%). In four studies (9%), the impact was on patients’ own costs, whereas in 14 studies (33%), it was on health care provider’s costs. In 27 (63%) studies, health care costs decreased, whereas in 14 (33%), there was no change, and in two (5%) studies, the costs increased. The impact was targeted to medicine costs (n = 29, 67%), laboratory test costs (n = 8, 19%), total health care utilization costs (n = 3, 7%), diagnostic testing costs (n = 2, 5%), and radiography costs (n = 2, 5%).
Most of the articles (
n = 32, 74%) have based their assessments on calculations on differences in costs between intervention and control group. In eight studies (19%), the authors have expanded the intervention group costs changes to large groups or for longer time. In one study [
29], the authors have performed cost-effectiveness analyses, and in two studies, costs that were reported were costs changes during intervention period.
The two studies [
30,
31] with increased costs had minor increases in costs allocated to patients. When the impact was allocated to the health care unit, the de-implementation either decreased costs (
n = 12, 86%) or had no effect on costs (
n = 2, 14%). In six studies, the authors estimated the impact on health care costs. De-implementation influenced laboratory test costs (
n = 6), medicine costs (
n = 5), diagnostic testing costs (
n = 2), radiology costs (
n = 2), and total health care expenditure per visit (
n = 1). Table
4 shows the direction and size of the impact. The size of the impact was reported in different ways (Table
4).
Table 4
De-implementation impact on health care costs per allocated health care unit
| Diagnostic imaging, laboratory tests | Decreased | US $1.7 million | 2.7 milliona | Annual hospital charge |
| Laboratory tests | Decreased | US $35,000 | 54,300a | Annual |
| Drug treatment, AB | Decreased | US $14.94 | 15.0a | Per patient |
Feldman et al. (2013) [52] | Laboratory tests | Decreased | US $436,115 | 507,000a | Per hospital/6 months |
Shojania et al. (1998) [53] | Drug treatment, AB | Decreased | US $22,500 | 35,400a | Year |
Soumerai et al. (1993) [28] | Blood transfusion | Decreased | US $3300 | 5670a | Per day of educational visit |
Tierney et al. (1988) [54] | Diagnostic imaging, laboratory tests | Decreased | US $1.09 | 2.01a | Per patient |
Tierney et al. (1990) [55] | Diagnostic imaging, laboratory tests | Decreased | US $6.68 | 11.20a | Per patient |
Torrente et al. (2020) [56] | Drug treatment | Decreased | US $234,893 | 245,000a | Year in Argentina |
Auleley et al. (1997) [57] | Diagnostic imaging | Decreased | 130,000 FRF | 35,400b | In 5 hospitals |
| Drug treatment, AB | Decreased | 8.9 FRF | 1.52b | Per episode |
| Drug treatment, AB | Decreased | 0.45–0.47 CNY | 0.08b | Per visit |
| Diagnostic imaging | Unchanged | NA | | |
Sedrak et al. (2017) [61] | Laboratory tests | Unchanged | NA | | |
Of the 25 studies, which did not detail allocation of the impact, 14 (56%) reported a decrease in costs, whereas 11 (44%) reported no change (Table
5). The impact was calculated in twelve studies (48%) and estimated in five studies (20%). In the rest of studies, it was not possible to assess from the report whether the impact was calculated or estimated. In most of the studies (
n = 20, 80%), the de-implementation mainly influenced the costs of medicine and laboratory tests. The change in reported health care cost varied between US $12.6 per patient to US $80.4 million per country. Of these 25 studies, 15 reported the impact in a monetary measure using different currencies (Table
5).
Table 5
De-implementation impact on health care costs in studies, not specifying to whom change was allocated
Alexander et al. (1996) [35] | Rehabilitation | Decreased | US $319,000/101 patient | 516,000/101 patientb |
| Drug treatment | Decreased | US $19,740/year | 45,800/yearb |
Chazan et al. (2007) [62] | Drug treatment, AB | Decreased | US $186/4-month season/patient | 238/4-month season/patientb |
Dormuth et al. (2012) [37] | Drug treatment | Decreased | US $465,000/2 years | 550,000/2 yearsb |
Meeker et al. (2014) [63] | Drug treatment, AB | Decreased | US $70.4 million/annual/country (USA) | 80.4 million/annual/country (USA)b |
| Drug treatment | Decreased | US $2000/3 months | 2240/3 monthsb |
| Drug treatment | Unchanged | US $331/patient | 491/patientb |
| Drug treatment, AB | Decreased | 16,130 AUD/3 months/56 GPs | 21,815/3 months/56 GPsd |
| Drug treatment, AB | Decreased | 273 AUD/doctor | 378/doctor $d |
Butler et al. (2012) [26] | Drug treatment, AB | Decreased | 830 GBP/year/practice | 1410/year/practicea |
Gulliford et al. (2019) [38] | Drug treatment, AB | Unchanged | 51-GBP annual cost/patient | 71.4/annual cost/patienta |
Coenen et al. (2004) [42] | Drug treatment, AB | Decreased | 7 EUR/patient | 12.6/patientc |
Danaher et al. (2009) [66] | Drug treatment, AB | Unchanged | 58.67 EUR | 127.4c |
Le Corvoisier et al. (2013) [67] | Drug treatment, AB | Decreased | 706 EUR | 1073c |
| Drug treatment, AB | Unchanged | 18 EUR/patient | 31.26/patientc |
Bernal-Delgado et al. (2002) [69] | Drug treatment | Unchanged | NA | |
Cummings et al. (1982) [70] | Diagnostic imaging, laboratory tests | Decreased | NA | |
Hamilton et al. (2007) [71] | Drug treatment | Unchanged | NA | |
Naughton et al. (2009) [29] | Drug treatment, AB | Unchanged | NA | |
Pagaiya et al. (2005) [72] | Drug treatment, AB and others | Decreased | NA | |
| Drug treatment | Unchanged | NA | |
Ruangkanchanasetr et al. (1993) [74] | Laboratory tests | Unchanged | NA | |
| Drug treatment, AB | Unchanged | NA | |
| Drug treatment, AB and injections | Decreased | NA | |
| Drug treatment, AB | Unchanged | NA | |
| Drug treatment, AB | Unchanged | NA | |
The 43 studies that reported impact on health care costs used 15 different de-implementation strategies. The most common strategies were educational meetings for groups (n = 14, 33%), educational materials (n = 13, 30%), audit and feedback (n = 8, 19%), educational meetings for individuals (n = 6, 14%), treatment algorithm (n = 5, 12%), educational materials for patients (n = 5, 12%), and developing clinical practice guidelines (n = 3, 7%). Two studies used public release of performance data and patient-mediated interventions. The strategies used in one study included financial incentives for health care workers, local consensus process, local opinion leaders, managerial supervision, and routine patients-reported outcome measures.
Total costs of de-implementation and the impact on health care costs were reported in seven articles (14%), while unit costs and impact on health care costs were reported in five (10%) articles (Table
6). The articles by Zwar et al. [
27] and Butler et al. [
26] reported both total and unit costs, and the unit costs were in the same unit as the impact was reported. In two studies [
27,
28], the intervention unit costs were less than their impact on health care costs. In the study by Butler et al. [
26], the authors commented that their study decreased health care costs, but the intervention costs exceeded the savings.
Table 6
De-implementation costs and impact on health care costs in USD (converted by authors in October 2022)
Alexander et al. (1996) [35] | Rehabilitation | 9710b | NA | 516,000b/101 patient |
| Drug treatment | NA | 232b/doctor | 45,800b/year |
Butler et al. (2012) [ 26] | Drug treatment, AB | 163,000a | 4950a/health care unit | 1410a/health care unit |
Coenen et al. (2004) [42] | Drug treatment, AB | 6845c | 280c/doctor | 12.6c/patient |
Dormuth et al. (2012) [37] | Drug treatment | 118,000b | NA | 550,000b/2 years |
Gulliford et al. (2019) [38] | Drug treatment, AB | 747,000a | NA | 71.4a/patient |
| Drug treatment | 616b | NA | 2240b/3 months |
Soumerai et al. (1993) [ 28] | Blood transfusion | NA | 1290b/day | 5670b/day |
| Drug treatment, AB | 22,175d | 284d/doctor | 378d/doctor |