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Abstract
Objectives This scoping review mapped and synthesised original research that identified low-value care in hospital settings as part of multicomponent processes.
Design Scoping review.
Data sources Electronic databases (EMBASE, PubMed, CINAHL, PsycINFO and Cochrane CENTRAL) and grey literature were last searched 11 July and 3 June 2022, respectively, with no language or date restrictions.
Eligibility criteria We included original research targeting the identification and prioritisation of low-value care as part of a multicomponent process in hospital settings.
Data extraction and synthesis Screening was conducted in duplicate. Data were extracted by one of six authors and checked by another author. A framework synthesis was conducted using seven areas of focus for the review and an overuse framework.
Results Twenty-seven records were included (21 original studies, 4 abstracts and 2 reviews), originating from high-income countries. Benefit or value (11 records), risk or harm (10 records) were common concepts referred to in records that explicitly defined low-value care (25 records). Evidence of contextualisation including barriers and enablers of low-value care identification processes were identified (25 records). Common components of these processes included initial consensus, consultation, ranking exercise or list development (16 records), and reviews of evidence (16 records). Two records involved engagement of patients and three evaluated the outcomes of multicomponent processes. Five records referenced a theory, model or framework.
Conclusions Gaps identified included applying systematic efforts to contextualise the identification of low-value care, involving people with lived experience of hospital care and initiatives in resource poor contexts. Insights were obtained regarding the theories, models and frameworks used to guide initiatives and ways in which the concept ‘low-value care’ had been used and reported. A priority for further research is evaluating the effect of initiatives that identify low-value care using contextualisation as part of multicomponent processes.
- Quality in health care
- Change management
- International health services
- Rationing
- Hospitals
Data availability statement
All data relevant to the study are included in the article or uploaded as online supplemental information. No additional data available.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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STRENGTHS AND LIMITATIONS OF THIS STUDY
The current study reviewed evidence related to identification processes that extended beyond use of pre-existing list-based low-value care initiatives as specific tests, services or procedures may not be of low-value in all settings or circumstances and contextualisation is required.
The focus on multicomponent processes to identify low-value care, methodology and framework synthesis of findings was guided by process theories and a framework of health service overuse adding to the rigour of the review.
Unclear reporting in some original studies meant authors were contacted for clarification.
Introduction
It has been estimated that 10%–30% of healthcare worldwide is wasteful, of little or no value, or harmful to patients.1 2 Using scarce resources to deliver low-value care is an important health system concern with opportunity cost implications, whereby resources could have been allocated to alternative care with potentially greater benefit.3 Identifying areas of low-value care is an important first step that must be taken prior to implementing strategies to address this issue.4
While a range of interventions for reducing or deimplementing low-value care has been the focus of prior studies, including literature reviews,5–7 there has been considerably less focus on processes to identify low-value care practices that should be addressed. List-making initiatives to identify low-value care have included Choosing Wisely lists of low-value tests and procedures,8 Royal Australasian College of Physicians (RACP) Evaluating Evidence, Enhancing Efficiencies initiative (EVOLVE) campaigns4 and National Institute for health and Care Excellence (NICE) guidelines.9 However, recent studies and commentaries have indicated the need to explore identification beyond list-based initiatives10 11 as specific tests, services or procedures may not be of low value in all settings or circumstances.1 12
In the context of a healthcare system or improvement being ‘a process; dynamic, fluid and constantly moving’ and the most complex of human environments,13 14 identification processes are not static and ideally should be conducted as part of cycles that include identifying factors contributing to the problem, deimplementing low-value care or implementing better care.15 16 Actions to deimplement low-value care include removing, reducing, replacing or revising that care.17 18
Multiple essential components of processes have been reported as key for identifying and prioritising low-value care services: evidence that a service is of low value; the extent of actual use of the lower value service; and stakeholder engagement.14 19 The latter two components have been considered essential for contextualising identification and prioritisation processes to determine whether care is low value or not in the host environment in which the intervention is implemented.4 19 20 Using multicomponent processes to identify and address low-value care, defined as those with two or more components, aligns with frameworks on health service overuse and deimplementation,19 21 and also with theory regarding identification and prioritisation in process models and theories of deimplementation.22–24
As part of processes to identify the extent of the low-value care, defining and understanding harms, resources, waste and prevalence of the potential low-value care has been considered important7 25 but has received minimal attention in published literature.25 Of these concepts, only harms are included in a commonly used definition of low-value care which is any form of healthcare service and/or intervention which confers little or no benefit, may cause patient harm, or yields marginal benefits at a disproportionately high cost.3
Healthcare systems have common broad contextual features that extend across settings that may influence low-value care such as hospitals, primary care and communities. However, there are also narrower subsets of contextual features that differ between these settings. For this reason, we chose to focus on hospital settings, which include a different make-up of teams, more frequent social interactions, social status hierarchies that revolve around medical specialisation and arguably fewer opportunities to develop patient–clinician relationships than other settings.26–28 These differences in hospital settings have implications for changing healthcare professional behaviours that may differ to other settings.27
Contextualisation in healthcare settings refers to the processes involved in adapting, delivering and monitoring healthcare. Common contextual factors, for example, barriers and enablers influencing the delivery and deimplementation of low-value care in healthcare include culture, lack of agreement regarding terminology or optimal approaches, evidence of the low-value care and clinician resistance to change.19 29
A scoping review was chosen to map and synthesise evidence, which in turn was used to develop a user-friendly toolkit to assist clinicians in identifying low-value care in hospitals. Consistent with the objectives of a scoping review, we also intended to clarify the concept of low-value care and to identify knowledge gaps to inform subsequent research to deimplement low-value care.30
Building on previous literature and conceptual work, our specific areas of investigation related to the identification of low-value care in hospitals were: (1) defining low-value care; (2) contextualisation; (3) components of processes used to identify and address low value; (4) elements used in identification processes (including frequency, costs, harms and waste); (5) theories, models and frameworks; (6) resources and tools to support identification; and (7) study outcomes and the effect of multicomponent processes involving identification.
Methods
The primary research question was: what are the key concepts and gaps in the evidence regarding multicomponent processes used to identify low-value care in hospital settings with a view to deimplementing that low-value care? For the sake of brevity the phrase ‘identifying low-value care’ will include prioritisation processes throughout the paper. Joanna Briggs Institute methodology for scoping reviews30 was used in deciding to undertake the review, guiding Population Concept, Context elements of the inclusion criteria, and data extraction. Study sources included original empirical studies and reviews with an original process component (eg, a prioritisation exercise). The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) extension for Scoping Reviews31 was used for reporting. The five key steps of the Arksey and O’Malley methodological framework for conducting a scoping review were followed and have been used to structure reporting of the methods: identifying the research question and relevant studies; study selection; charting the data and collating, summarising and reporting results.32 A review protocol was completed prior to commencement of the review but was not published.
Patient and public involvement
Patients or the public were not involved in the design, conduct or reporting of this review.
Identifying relevant studies
Electronic databases of EMBASE, PubMed, CINAHL, PsycINFO and Cochrane CENTRAL were searched with no language or date restrictions. Three sources of grey literature recommended for systematic reviews33 were also searched to identify relevant clinical practice guidelines, reports and papers: (1) grey literature databases (Canadian Agency for Drugs and Technologies in Health, Agency for Healthcare Research and Quality, WHO, World Bank, Creating Value Based Healthcare, Maastricht University); (2) a customised google search using google advanced and (3) websites on low-value care (RACP EVOLVE, UK NICE ‘do not do’ recommendations, Choosing Wisely). The first 10 pages of google searches were screened for potentially relevant titles and text to ensure the most relevant items were captured but that the search results remained manageable.33 Handsearching the reference lists of included records was also conducted to identify relevant documents.34 The search strategy was developed with the input of two medical librarians and consisted of terms pertinent to a single theme of “low value” using the terms “low value” OR “low-value” OR “low-added value” for databases (detailed in online supplemental file 1) with database searches last updated 11 July 2022 and grey literature 3 June 2022. A medical librarian removed most duplicates using duplicate detection settings in EndNote (V.20), with remaining duplicates removed by hand by the authors.
Supplemental material
Study selection
Six authors screened studies for selection, initially each screening the same 100 consecutive records to ensure selection consistency. This was followed by discussion of the rationales for study selection and revision of the selection criteria to improve clarity. Following this, author pairs independently screened titles and abstracts for eligibility. In cases of conflict or ambiguity, full-text articles were independently examined by two to four authors. Discrepancies after review of full-text articles were resolved by consensus of five authors. Study eligibility criteria are detailed in table 1. Studies where the low-value care was identified using a list-based initiative alone, such as Choosing Wisely, were excluded except where there was evidence of contextualisation of the list as the care listed may not be generalisable to all settings or circumstances. Limitations to generalisability may be due to the lack of representation of diverse resources, infrastructure and people at multiple levels of hospital settings in the development of the list.35 We had initially thought that if we detected many non-English studies that would otherwise be eligible, that it would not be possible to translate each of these articles into the English language due to the limited resources we had available to complete this review. However, given only one study was found for which a full English translation was not readily available, and that study had an English title and abstract readily available we did not exclude any studies on the basis of language. Furthermore, we were later able to access an English translation of that article which confirmed the accuracy of the initial extraction. Records with only abstracts available were also included to capture recent research that might only be available as a conference abstract. Inclusion of these abstracts will permit future review authors to investigate these papers or studies in full if available.36 Definitions of terms related to inclusion criteria and the rationale for these criteria are detailed in online supplemental file 2.
Supplemental material
Inclusion and exclusion criteria
Identifying low-value care as part of a multicomponent process, defined as two or more components, was the focus of the current review. The rationale for the focus on two or more components was theory informed, as two or more components of identification and prioritisation have been included in process models and theories of deimplementation,22–24 and frameworks on health service overuse and deimplementation.19 21 Broader human-centred design methods using the discover, design, build and test framework and the multiphased optimisation strategy framework also support the need for multiphased process components to identify or design intervention components in preparation for subsequent optimisation and evaluation, to achieve the best-possible outcomes.37
Charting data
A data extraction form was developed by two authors (ZT and MA) using a standardised template in Microsoft Excel that was piloted by two authors (SN and MA) who each extracted data from three relevant articles and two web pages. The extraction form was then revised to include explanations of each of the fields and examples of data to be extracted. Further data was extracted by one author (ZT) using the revised spreadsheet, after which minor revisions to the explanations were made. Data from each included paper were then independently extracted by one of seven authors (ZT, SS, HC, MA, KW, BA and SN) and was verified by a different author (ZT and HC). Disagreements were resolved through consensus of those involved in extraction. Authors of records were contacted to seek clarification where information presented was unclear to the review authors and could not be inferred from other information provided in the record.
Collating, summarising and reporting of the results
A framework synthesis38 was used to structure the reporting, mapping what is known and not known in the review and allowing the complexity of low-value care to be explored using theory-informed frameworks in the literature.38 39 The framework synthesis was structured using the seven research areas of focus of the review (defining low-value care; contextualisation; components of identification processes; elements used in identification or prioritisation including harms and waste; theories, models and frameworks; resources and tools developed for identification; study outcomes and effect of multicomponent processes involving identification). In addition, a framework of transdisciplinary approaches to identify overuse in health services, developed from a critical interpretive synthesis and stakeholder engagement process, was used for the framework synthesis that targeted: (1) four groups of contextual factors facilitating overuse (culture at multiple levels; lack of agreement on framing or terminology such as disinvestment; health-system arrangements such as lack of awareness of evidence and lack of evidence regarding optimal approaches to reduce overuse); and (2) three components of a process to identify overused health services (using the best available data, research evidence and guidelines; conducting jurisdictional scans to identify services overused in other health systems and whether those services are used locally; and engaging stakeholders and people with lived experience to prioritise services for deimplementation).19 The intervention categories by Colla et al7 were used to summarise the deimplementation components of interventions (patient cost sharing and value-based insurance design, patient education, provider report cards, pay-for performance, insurer restrictions, risk sharing, clinical decision support, clinician education, provider feedback or a combination of these components). Results are reported using narrative and descriptive summaries in visual and table display formats.
Results
Description of included studies
Of the 6804 records (6561 and 243 grey literature) records screened, 27 records published between 2014 and 2022 met our selection criteria (figure 1).
PRISMA diagram. *Numbers in brackets for database records is provided as number from the initial search+number from the updated search=total number. **Duplicate records removed by hand during screening (n=62 initial search, n=1 updated search).
Table 2 outlines the characteristics of included studies which comprised 21 original research articles, 4 conference abstracts and 2 review papers. All included records originated from high income countries, with the USA (seven records), Canada (four records) and Australia (four records) being the most represented countries. Nine records were from countries where the primary language spoken was not English. Two authors of included records were contacted to clarify the relevance of the record to care in hospital settings, one of whom responded.
Study characteristics
A diverse range of clinical settings were targeted, spanning specific wards or services through to whole of hospital, health system and global approaches. Three of 27 studies targeted paediatric hospitals or health services specifically.40–42 The entire continuum of care (primary care to specialist care or healthcare system) was covered by six records.19 43–47 Four of 27 records focused on practice by a specific profession or discipline40 48–50 with two records targeting practice by the allied health disciplines of nutrition50 and physical therapy.49 The majority of records (23 of 27 records) focused on the preimplementation phase of research. Four of 27 records examined evaluation, either by developing evaluation measures8 or evaluating intervention effectiveness.41 51 52
Defining low-value care
Nearly half of the included studies (11 records) included an explicit definition of low-value care8 15 19 43 45 47 49 53–56 (online supplemental file 3). Some studies failed to apply the explicit definitions or key concepts of low-value care to their study methods (two records) or applied different definitions or key concepts to those explicitly stated (nine records). Of the records that explicitly defined low-value care or articulated key concepts aligned with low-value care (25 records), most used concepts of benefit or value (11 records), risk or harm (10 records) or overuse (6 records). Five of the 11 records using an explicit definition of low-value care defined it in terms of cost; 2 targeted the patient level and 3 the service level with the latter referring to cost exceeding benefit.
Supplemental material
Contextualisation
Of the 25 records with evidence of contextualisation of identification processes, the most common focus was on a national health system in 14 records (online supplemental file 4). Five records focused on a single centre or single integrated healthcare delivery system. Using the 2 components of contextualisation applied in the current review (evidence of actual use of the targeted low-value care, and engagement of relevant stakeholders), over half (15 records) applied both criteria fully or partially. The extent to which stakeholders were relevant to the context or represented those involved in the targeted low-value care was not reported or supported in 16 records.
Supplemental material
Barriers to the identification of low-value care were discussed in four records,15 19 42 57 enablers in three records10 42 45 and other contextual factors in two records.15 41 Some contextual factors aligned with the four factors driving overuse that were used for the framework synthesis.19 The barrier from included studies that aligned with this framework was difficulty applying what were deemed ideal prioritisation criteria (ie, availability of evidence a service is ineffective or harmful, patient safety, health and cost impacts of deadoption and use of the low-value service) due to the lack of detailed information available thus the need to apply alternative criteria.15 Enablers were reported as engagement, expertise and leadership roles of an expert advisory committee from the outset of the study, which was reported as ensuring relevancy within the study context10; a Delphi method which enabled a range of expertise to be included and decision-making when working with low level or limited evidence42; and the participation of stakeholders as a means of including their knowledge and addressing trust.45
Factors that did not align with the framework synthesis19 but which were reported as barriers to identification processes were the lack of: diversity of working group members including non-physicians42; local stakeholder involvement to ensure relevance in the local context15 and an arbitrary cut-off for services included in a top five list of low-value services based on consensus, which may miss important low-value services.57
Components of processes used to identify and address low-value care
All included records examined identification using two to seven components of multicomponent processes (online supplemental file 5). The most commonly described components used as part of processes to identify low-value care included initial consensus, consultation, ranking exercise or list development (16 records) and reviews of evidence (16 records). There was variability in the order of the components applied across studies. Of the records that included expert consensus, committee member or stakeholder engagement activities, participants were mostly clinicians and sample sizes ranged from n=646 55 57 to n=22.48 Where reported, sample sizes in studies that accessed patient record data to identify the extent of the low-value care ranged from 1012 records in four participating hospitals55 to 62 314 admissions.51 Only two records involved engagement with patients.43 47 In one of these records findings from three qualitative studies of focus groups with patients and caregivers and semistructured interviews with primary care physicians were used to obtain varied perspectives on low-value prescribing.47 In the other record, a 10-member panel including 2 patient representatives was formed to prioritise and assess a short list of 45 Choosing Wisely Canada recommendations.43
Supplemental material
Three records (11% of included records) included components of deimplementation processes following identification processes that targeted drug–drug interaction alerts (clinical decision support component),41 implementation of a diagnosis-related group payment scheme policy under the Taiwan National Insurance Scheme to reduce low-value preoperative surgical testing (pay-for-performance component),51 and implementing value-based medical education curriculum competencies with gynaecology oncology fellows (clinician education component).52
Elements used in identification processes (including frequency, costs, harms and waste)
The most common element used to identify or prioritise low-value care was the frequency of low-value care (14 records, 52%), followed by risk or harm to patients or quality and safety (9 records, 33%) and cost or resources (9 records, 33%) (figure 2, detailed in online supplemental file 6). In addition to cost, one record11 also used a budgetary impact filter to prioritise candidate technologies. Benefit, waste, acceptance (eg, foreseeable acceptance by the professional community),46 burden of disease (years lived with disability and disability-adjusted life-years)15 and variability58 were rarely considered as part of processes to identify low-value care.
Supplemental material
Most commonly used elements to identify or prioritise low-value care.
Using theories, models and frameworks and developing resources and toolkits
No theory, model or framework was mentioned, or used for contextualisation of identification or prioritisation processes. Further, no articles reported developing resources or a toolkit as part of the multicomponent process that involved identifying low-value care. Five records used, or made reference to potential use of, seven theories, models or frameworks19 45 46 50 59–61 as shown in figure 3.
Theories, models or frameworks used or referred to in included records.
Study outcomes and effect of multicomponent processes involving identification
Only three included studies were designed to evaluate outcomes as opposed to developing priorities, an intervention or evaluation plan, all of which included two or three components.41 51 52 The outcomes measured related to the frequency or predicted probability of low and high value care41 51 52 and patient outcome safety event data.41 Two studies reported findings in support of the processes41 52 and one study reported short-term somewhat positive outcomes but these were not sustained thus did not support the processes.51 The process components in these studies involved: consultation and a survey of clinicians41; a three-stage educational intervention, group process and implementation into practice as part of a quality improvement initiative52; and a reimbursement policy implementation process with identification involving a review of evidence, use of existing guidelines (eg, Choosing Wisely) and data audit.51
Discussion
Applying and reporting systematic contextualisation of identification and subsequent deimplementation processes was identified as a research gap. Over two-thirds of the included studies investigated actual use of the targeted low-value care and/or engagement of relevant stakeholders in identification processes at least partially; criteria deemed essential to contextualise the identification of low-value care in relevant theory and frameworks,19 20 which was encouraging. However, the extent to which relevant stakeholders represented those involved in the targeted low-value care was not reported or supported in over half of included records which is an area requiring further investigation. Without contextualising identification processes, deimplementation efforts may be wasteful or target the wrong care. The potential for transferability to other contexts may also be unclear.
Across the 27 included records, the most common process elements used to initially identify low-value care were a review of evidence and initial consensus, consultation, ranking or list development exercises. The frequency or prevalence of the low-value care was the element commonly used to determine the magnitude of the low-value care or to prioritise low-value care in the included studies, although as pointed out by others there may be challenges when relying solely on administrative data to determine actual use of the low-value care based on these elements.7 These challenges include administrative data not including the detail needed to identify some low-value care7 although relying solely on stakeholder processes such as a consensus meeting or survey to identify low-value care may also present challenges including recall and sampling biases.
There was at least some evidence of effect from the three included studies that evaluated multicomponent processes that included identification of low-value care. However, no information was reported regarding the components that were most effective. This finding corresponds to evidence regarding multicomponent interventions of low-value care more broadly from systematic reviews, whereby multicomponent interventions have been identified as more effective than single component interventions.6 7 62–65 In a systematic review of low-value medical services, higher complexity components in multicomponent interventions (eg, targeting organisational system change or involving multiple healthcare providers) were reported as most likely to achieve intended outcomes,6 which warrants investigation in relation to the identification of low-value care. No studies formally evaluated patient outcomes (except for safety events) or implementation outcomes including the sustainability and spread of effective programmes.
In the current review the involvement of people with lived experience of accessing health services in only 1% of studies indicates this is a research gap. People with lived experience of accessing healthcare could be engaged in identifying their values and preferences which could then be communicated to other levels of health systems.19 The public could also be involved in prioritising low-value care using forums like community juries at the policy level.64 However, stakeholder uncertainty about the role of the public in policy-making regarding disinvesting from low-value care has been reported.64
Approaches based on the theories, models or frameworks referred to in the included studies and process theories, models or frameworks may offer important guidance for future efforts to implement multicomponent approaches covering identification, prioritisation and deimplementation. These approaches have the potential to advance an understanding of, and develop, interventions to address the complexity of low-value care19 and ensure evaluations are robust.66
Two frameworks captured in the current review may be particularly useful to guide future studies to identify low-value care. One framework was developed based on a critical interpretive synthesis and stakeholder engagement on identifying overuse.19 Identification approaches detailed as part of this framework included the need for leaders to coordinate transdisciplinary approaches to identify and diagnose overuse and prioritise low-value care for removal,19 moving beyond list making initiatives. It is also worth mentioning a framework included in a record that was excluded from our review as it was not an original study. In that record the ‘Choosing Wisely De-Implementation Framework’ (based on behaviour science) was presented as a framework to develop, evaluate and scale up deimplementation interventions. The authors based the framework on a process to develop theory-informed interventions for health professional behaviour change.20 The first two phases of the approach involve identifying local priorities and barriers to implementing Choosing Wisely recommendations20 demonstrating recognition of the need for contextualisation of the identification.
Frameworks that did not arise from the review may also offer an important lens to capture the contextualisation of processes to identify low-value care, as part of a broader dynamic processes that aim to reduce or deimplement low-value care. Complex adaptive systems theory and dynamic explanatory theories could assist. Complex adaptive healthcare systems theory highlights the role of teams and leadership in identifying local needs and innovations based on those needs67 and suggests that key agents (brokers, boundary spanners and influencers) in systems such as hospitals should be identified alongside activities for improvement such as addressing low-value care.68 The process of identifying low-value care as part of a multicomponent process that begins with ‘labelling’ the value of care aligns with dynamic explanatory theory in that this process can be viewed as beginning the work of organising and identifying potential actions.14
Strengths, limitations and future directions
Our two contextualisation criteria were theory-informed but may have been too simplistic to pick up the complexities of contextualisation in identification processes, for example, the power, legitimacy and urgency of stakeholders that have been highlighted by others.69 While guidelines are lacking for reporting and conducting contextual assessments,70 future research to identify and prioritise low-value care and subsequent deimplementation efforts would benefit from contextual assessment with attention to matching the level of interest (eg, international, national, state, single centre) with data and stakeholder perspectives that represent that level or service, with careful consideration and reporting of power, equity and urgency that has been discussed by others.69 71 One included record could be used as an exemplar of methods that could be used in future research and evaluation efforts to obtain an in-depth understanding of context in relation to identifying low-value care.45 In that study ethnography identified the importance of engaging stakeholders in problem definition to avoid stakeholder feelings of disempowerment, and developing trust through data analysis that involved clinical experts.45
There were challenges identifying relevant records for reasons like titles and abstracts not always reflecting whether the identification of low-value care was included. However, systematic search guidance was followed including broadening the initial search strategy for sensitivity and consultation with a medical librarian experienced in conducting systematic reviews.72 In addition, several approaches were used to identify unpublished papers as recommended.33 34 Thus, we are reasonably confident that most relevant articles were included. A team of authors was involved in resolving any discrepancies regarding whether or not papers met eligibility criteria which assisted in ensuring consistency in our decision-making. Inconsistency in the application of, or lack of, explicit definitions or key concepts of low-value care in the methods of included studies indicates further work is required in elucidating and reporting of key concepts which would assist identification of relevant studies and comparison across studies.
Unclear reporting within original studies meant authors were contacted for clarification where it was difficult to make inferences from other details reported, for example, records referring to future implementation were interpreted as meaning the study was in the preimplementation phase. The evidence included in our review largely pertained to high-income countries (eg, the UK, the USA, Canada, Australia) thus may not generalise to dissimilar healthcare systems.
Conclusions
Gaps identified in this review were the lack of use and reporting of contextualisation, and involvement of people with lived experience of a health condition in identifying low-value care. Most multicomponent processes for identifying low-value care were limited to the preimplementation phase and few studies evaluated the effectiveness of implementing these processes in clinical settings. No studies evaluated the impact of the multicomponent processes on patient outcomes apart from patient safety. Therefore, a priority for further research is evaluating the effectiveness of initiatives that identify low-value care as part of multicomponent processes in clinical practice on patient, clinical and implementation outcomes. Other gaps identified in this review were the lack of initiatives in resource poor settings and countries, and application of clear definitions or key concepts to identifying low-value care. Few models, theories or frameworks were used to guide initiatives in included records, but guidance is offered for theories, models and frameworks that may assist in planning and implementing future multicomponent initiatives that involve identifying low-value care.
Data availability statement
All data relevant to the study are included in the article or uploaded as online supplemental information. No additional data available.
Ethics statements
Patient consent for publication
Acknowledgments
The authors wish to acknowledge the assistance of the Librarians Cameron Rutter and Catherine Haden in developing the search strategy. The design of Figure 3 was based on © Margie Nance via Canva.com.
References
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
X @tyack_z, @Hannah_E_Carter, @SameeraSenanay3
Contributors All authors meet the ICMJE as detailed by their contribution statement in the manuscript. All authors have made a substantial contribution to the conception or design of the work; or the acquisition, analysis or interpretation of data for the work; and drafting the work or reviewing it critically for important intellectual content. All authors have approved the manuscript for publication. All authors agreed to be accountable for aspects of the work they contributed to which are as follows: Concept and design: ZT, HC, MA, SN and SMM; Acquisition of data: ZT, HC, MA, SS, KW, SN and BA; Analysis and interpretation of data: ZT, HC, MA, SS, KW, SN, BA and SMM; Drafting of the manuscript: ZT; Critical revision of the paper for important intellectual content: ZT, HC, MA, SS, KW, SN, BA and SMM; Obtaining funding: SMM.
Funding Research reported in this publication was supported by the Medical Research Future Fund under grant number MRF9100000. The project was funded by a grant to Brisbane Diamantina Health Partners (now Health Translation Queensland) from the Health Systems Improvement and Sustainability (HSIS) Initiative. Queensland University of Technology received funding from BDHP to conduct the review.
Competing interests SMM was supported during the review period by an NHMRC fellowship (#1090440). KW discloses being supported by a grant, the Betty McGrath Health Care Delivery and Innovation Seeding Grant (Mater Research Limited), to Mater Health Limited. KW also received payments from The University of Queensland for lectures as Senior Lecturer (Honorary) and was co-chair of the Safer Baby Bundle Queensland Implementation Project Steering Committee.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.