Tijn Kool, MD PhD, is Full Professor Appropriate Care at the Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, the Netherlands.

Andrea M. Patey, PhD, is Senior Research Associate in the Centre for Implementation Research in the Clinical Epidemiology Program, Ottawa Hospital Research Institute, Canada.

Simone van Dulmen, PhD, is Senior Researcher in Appropriate and Sustainable Healthcare at the Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, the Netherlands.

Jeremy M. Grimshaw, MBChB, PhD, Senior Scientist in the Centre for Implementation Research in the Clinical Epidemiology Program, Ottawa Hospital Research Institute, Canada.

Preface x Chapter 1 Why Should We Reduce Medical Overuse? 1Karen Born and Wendy Levinson It Started with Quality Improvement 1 Then Came a Focus on Overuse 3 Overuse as a Global Healthcare Quality Concern 5 What Can Be Done to Address Overuse? 6 Choosing Wisely 7 What Can you Expect in the Following Chapters? 9 References 10 Chapter 2 Why Does Overuse Exist? 13Tijn Kool, Simone van Dulmen, Andrea M. Patey, and Jeremy M. Grimshaw A Multifactorial Challenge on Different Levels 13 Healthcare Professional Factors 14 Patient Factors 15 Preference for Acquiring Something 16 Clinical Care Context Factors 16 Absence of an Open Culture 17 Absence of Clear Leadership 17 Healthcare Organisation Factors 18 Insufficient Time 18 Lack of Coordination Amongst Healthcare Providers 19 Healthcare System Factors 19 Payment System that Rewards Volume 19 Influence of the Pharmaceutical and Medical Device Industry 20 Healthcare Insurance Policy 20 Key Points 20 References 21 Chapter 3 Why Is It So Hard to Change Behaviour and How Can We Influence It? 23Jill J. Francis, Sanne Peters, Andrea M. Patey, Nicola McCleary, Leti van Bodegom- Vos, and Harriet Hiscock The Challenge of Behaviour Change 24 Is The Behaviour a Routine? 24 Is The Behaviour Rewarding? 24 Do Habits or Routines Play a Role in Sustaining the Behaviour? 26 Four Crucial Questions to Address Before Working to Support Behaviour Change 28 Why Is It So Difficult to Change the Behaviour of Healthcare Professionals? 30 Designing Interventions to Change Behaviour 35 Summary 36 Sources of Information for Supporting Practice Change Among Healthcare Professionals 36 References 36 Chapter 4 How Can We Reduce Overuse: The Choosing Wisely De- Implementation Framework 41Jeremy M. Grimshaw and Andrea M. Patey Introduction 41 The Choosing Wisely De- Implementation Framework 44 Phase 0: Identification of Potential Areas of Low- Value Healthcare 44 Phase 1: Identification of Local Prioritiesfor the Implementation of Recommendations 45 Phase 2: Identification of Barriers and Enablers to Implementing Recommendations and Potential Interventions to Overcome These 46 Phase 3: Evaluation of the Implementation 48 Phase 4: Spread of Effective Implementation Programs 49 Key Points 50 References 51 Chapter 5 How Can You Engage Patients in De- Implementation Activities? 54Stuart G. Nicholls, Brian Johnston, Barbara Sklar, and Holly Etchegary What Is Patient Engagement and Why is it Relevant to De- Implementation? 54 Making a Patient Engagement Plan 56 The Level of Engagement 57 Area 1 - Patient Engagement in Agenda Setting and Prioritisation 61 Area 2 - Patient Engagement in the Design and Conduct of De- Implementation Activities 64 Area 3 - Patient Engagement in Spread 65 Important Considerations when Engaging Patients 66 Key Points 68 Sources of Information 69 General Resources 69 Planning Tools 69 Patient Engagement Methods 70 Evaluation Tools 70 References 70 Chapter 6 Identifying Potential Areas of Low- Value Healthcare- Phase 0 73Moriah E. Ellen, Saritte M. Perlman, and Jeremy M. Grimshaw How to Identify Low- Value Care? 73 Resources to Identify Low- Value Care 75 Recommendation Lists 76 Clinical Practice Guidelines 77 Health Technology Assessments 77 Evidence Syntheses and Systematic Reviews 78 From Identification to Measurement 78 Key Points 84 Sources of Further Information 84 References 84 Chapter 7 Measuring Low- Value Care and Choosing Your Local Priority (Phase 1) 88Carole E. Aubert, Karen Born, Eve A. Kerr, Sacha Bhatia, and Eva W. Verkerk Choosing Your Local Priority 89 Measuring Low- Value Care 89 Baseline Measurements 90 Estimating Improvement Potential 91 Evaluating De- Implementation Effects 91 Measuring Unintended Consequences 94 Measurement Methods and Data Source 95 Setting Specific, Measurable, Achievable, Relevant, and Time- Bound (SMART) Targets 98 Providing Data and Feedback to Stakeholders 98 Key Points 100 References 100 Chapter 8 Identifying Target Behaviours and Potential Barriers to Change (Phase 2a) 103Andrea M. Patey, Nicola McCleary, Justin Presseau, Tijn Kool, Simone van Dulmen, and Jeremy M. Grimshaw The Importance of Fully Understanding the Problem 104 Getting Started 104 Identifying Who Needs to do What Differently 105 Using the Action, Actor, Context, Target, Time (Aactt) Framework 106 Identifying Drivers of Current Behaviour and Barriers and Enablers to Changing Behaviour 109 Collecting Data 112 Interviews 112 Focus Groups 114 Surveys 116 Analysing the Data 118 Narrowing Down the Drivers or Barriers Identified 118 Key Points 119 Useful Resources 120 References 120 Appendix: Sample Interview Guide for Healthcare Providers Using the Tdf 122 Introduction Script 122 Background 123 Chapter 9 Selecting De-Implementation Strategies and Designing Interventions: Phase 2b 131Justin Presseau, Nicola McCleary, Andrea M. Patey, Sheena McHugh, and Fabiana Lorencatto What Do You Need To Do Before Selecting De- Implementation Strategies? 132 Ten General Principles to Consideras you Develop a de- Implementation Intervention 132 1. There Are No Magic Bullets: Design Your De- Implementation Intervention to Address Specific Barriers and Enablers 132 2. De- Implementation Interventions Are Often Also Implementation Interventions when Substituting One Practice with Another 133 3. Routinised, Habitually Performed Care May Be Operating Semi- Automatically 134 4. Follow the Evidence Wherever Possible when Designing Your De- Implementation Intervention 135 5. Avoid the Tower of Babel: Leverage Existing Listsof Change Strategies and Use Them to Help Match Specific Strategies to Identified Barriers/Enablers 136 6. Avoid Conflating Intervention Content with Its Method of Delivery 139 7. Decide on Tailoring and Adaptation 140 8. Co- Development, User- Centred Design to Enhance Feasibility, Acceptability, and Implementability 140 9. Prioritise Equity 141 10. Describe How the Strategy Works by Developing a De- Implementation Logic Model of Change 142 Key Points 143 Sources 144 References 144 Chapter 10 Evaluating De- Implementation Interventions: Phase 3 149Beatriz Goulao, Eva W. Verkerk, Kednapa Thavorn, Justin Presseau, and Monica Taljaard Why Should We Evaluate? 150 Outcomes 150 Types of Evaluations 151 Randomised Evaluations 152 Non- Randomised Evaluations 154 Selecting the Most Appropriate Evaluation Method 156 How and Why Does the Intervention Work? 158 Does the Intervention Offer Good Value for Money? 160 Key Points 161 References 162 Chapter 11 Preserving Results and Spreading Interventions: Phase 4 166Simone van Dulmen, Daniëlle Kroon, and Tijn Kool Why Are Sustainability and Spread So Important? 166 What Is Sustainability? 167 Factors Influencing Sustained Change 168 Factors Related to the Process 168 Factors Related to Staff 170 Factors Related to the Organisation 170 How Can You Facilitate Sustainability? 171 Assessing Sustainability 172 Sustainability and Culture 173 Spreading Successful De- Implementation Interventions 174 Scaling Strategy 175 De- Implementation Intervention 176 Adopters or Adopting Organisation 177 External Context 177 Key Points 178 References 178 Chapter 12 Training the Next Generation of Healthcare Providers to Address Overuse and Avoid Low- Value Care 181Brian M. Wong, Christopher Moriates, Lorette Stammen, and Karen Born Introduction 182 High- Value Care Competencies 182 Teaching Students and Trainees To Provide High- Value Care 183 Educational Changes to the Formal Curriculum 183 Faculty Role Modellingand Supportive Learning Environments 186 Assessing High- Value Care Learning Outcomes 190 Enablers of Educational Change 191 Aligning Continuing Professional Development and Quality Improvement 192 Key Points 193 Sources 196 References 196 Chapter 13 Examples from Clinical Practice 199Simone van Dulmen, Daniëlle Kroon, Tijn Kool, Kyle Kirkham, and Johanna Caro Mendivelso Introduction 199 References 215 Chapter 14 Starting Tomorrow 217Tijn Kool, Andrea M. Patey, Jeremy M. Grimshaw, and Simone van Dulmen Index 221