Article Text

Original research
Barriers and facilitators to reduce low-value care: a qualitative evidence synthesis
  1. SA van Dulmen1,
  2. CA Naaktgeboren2,
  3. Pauline Heus3,
  4. Eva W Verkerk1,
  5. J Weenink4,
  6. Rudolf Bertijn Kool1,
  7. Lotty Hooft5
  1. 1Scientific Institute for Quality of Healthcare, IQ Healthcare, Radboud University Medical Centre, Nijmegen, The Netherlands
  2. 2Julius Center for Health Sciences and Primary Care, University Medical Center Utrech, Utrecht University, Utrecht, The Netherlands
  3. 3Cochrane Netherlands, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
  4. 4Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
  5. 5Cochrane Netherlands, University Medical Center Utrecht, University of Utrecht, Utrecht, The Netherlands
  1. Correspondence to Dr SA van Dulmen; simone.vandulmen{at}


Objective To assess barriers and facilitators to de-implementation.

Design A qualitative evidence synthesis with a framework analysis.

Data sources Medline, Embase, Cochrane Library and Rx for Change databases until September 2018 were searched.

Eligibility criteria We included studies that primarily focused on identifying factors influencing de-implementation or the continuation of low-value care, and studies describing influencing factors related to the effect of a de-implementation strategy.

Data extraction and synthesis The factors were classified on five levels: individual provider, individual patient, social context, organisational context, economic/political context.

Results We identified 333 factors in 81 articles. Factors related to the individual provider (n=131; 74% barriers, 17% facilitators, 9% both barrier/facilitator) were associated with their attitude (n=72; 55%), knowledge/skills (n=43; 33%), behaviour (n=11; 8%) and provider characteristics (n=5; 4%). Individual patient factors (n=58; 72% barriers, 9% facilitators, 19% both barrier/facilitator) were mainly related to knowledge (n=33; 56%) and attitude (n=13; 22%). Factors related to the social context (n=46; 41% barriers, 48% facilitators, 11% both barrier/facilitator) included mainly professional teams (n=23; 50%) and professional development (n=12; 26%). Frequent factors in the organisational context (n=67; 67% barriers, 25% facilitators, 8% both barrier/facilitator) were available resources (n=28; 41%) and organisational structures and work routines (n=24; 36%). Under the category of economic and political context (n=31; 71% barriers, 13% facilitators, 16% both barrier/facilitator), financial incentives were most common (n=27; 87%).

Conclusions This study provides in-depth insight into the factors within the different (sub)categories that are important in reducing low-value care. This can be used to identify barriers and facilitators in low-value care practices or to stimulate development of strategies that need further refinement. We conclude that multifaceted de-implementation strategies are often necessary for effective reduction of low-value care. Situation-specific knowledge of impeding or facilitating factors across all levels is important for designing tailored de-implementation strategies.

  • quality in health care
  • public health
  • organisation of health services

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:

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  • SvD and CN are joint first authors.

  • Twitter @tijnkool

  • Contributors All authors contributed to the design of the study, data collection and analysis of data. SAvD and CAN drafted the manuscript. PH, EWV, JW, RBK and LH critically revised the manuscript; all authors approved the final version.

  • Funding This study was funded by “To do or not to do” a project of the Citrien Fonds, a grant from the Dutch Government. ‘To do or not to do. Reducing low-value care’. Grant number: 80-83920-98-101.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement All data relevant to the study are included in the article or uploaded as supplementary information. The data presented in this paper will be made available upon reasonable request. A list of articles included in this review has been made available in the appendix.

  • 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.