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De-implementing wisely: developing the evidence base to reduce low-value care
  1. Jeremy M Grimshaw1,2,
  2. Andrea M Patey1,
  3. Kyle R Kirkham3,4,
  4. Amanda Hall5,
  5. Shawn K Dowling6,
  6. Nicolas Rodondi7,8,
  7. Moriah Ellen9,10,11,
  8. Tijn Kool12,
  9. Simone A van Dulmen12,
  10. Eve A Kerr13,14,
  11. Stefanie Linklater1,
  12. Wendy Levinson15,16,
  13. R Sacha Bhatia17,18
  1. 1 Centre for Implementation Research, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
  2. 2 Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
  3. 3 Department of Anesthesia and Pain Management—Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
  4. 4 Department of Anesthesia, Women’s College Hospital, Toronto, Ontario, Canada
  5. 5 Primary Healthcare Research Institute, Faculty of Medicine, Memorial University of Newfoundland, St. John’s, Newfoundland, Canada
  6. 6 Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
  7. 7 Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
  8. 8 Department of General Internal Medicine, Inselspital University Hospital Bern, Bern, Switzerland
  9. 9 Department of Health Systems Management, Guilford Glazer Faculty of Business and Management and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
  10. 10 McMaster Health Forum, McMaster University, Hamilton, Ontario, Canada
  11. 11 Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
  12. 12 Radboud Institute for Health Sciences, IQ Healthcare, Radboud University Medical Center, Nijmegen, Gelderland, The Netherlands
  13. 13 Department of Internal Medicine and Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, USA
  14. 14 VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
  15. 15 Department of Medicine, University of Toronto, Toronto, Ontario, Canada
  16. 16 St. Michael’s Hospital, Toronto, Ontario, Canada
  17. 17 Women’s College Research Institute, Women’s College Hospital, Toronto, Ontario, Canada
  18. 18 Women’s College Hospital Institute for Health System Solutions and Virtual Care, Women’s College Hospital, Toronto, Ontario, Canada
  1. Correspondence to Dr Jeremy M Grimshaw, Ottawa Hospital Research Institute, Ottawa, ON K1Y 4E9, Canada; jgrimshaw{at}


Choosing Wisely (CW) campaigns globally have focused attention on the need to reduce low-value care, which can represent up to 30% of the costs of healthcare. Despite early enthusiasm for the CW initiative, few large-scale changes in rates of low-value care have been reported since the launch of these campaigns. Recent commentaries suggest that the focus of the campaign should be on implementation of evidence-based strategies to effectively reduce low-value care. This paper describes the Choosing Wisely De-Implementation Framework (CWDIF), a novel framework that builds on previous work in the field of implementation science and proposes a comprehensive approach to systematically reduce low-value care in both hospital and community settings and advance the science of de-implementation.

The CWDIF consists of five phases: Phase 0, identification of potential areas of low-value healthcare; Phase 1, identification of local priorities for implementation of CW recommendations; Phase 2, identification of barriers to implementing CW recommendations and potential interventions to overcome these; Phase 3, rigorous evaluations of CW implementation programmes; Phase 4, spread of effective CW implementation programmes. We provide a worked example of applying the CWDIF to develop and evaluate an implementation programme to reduce unnecessary preoperative testing in healthy patients undergoing low-risk surgeries and to further develop the evidence base to reduce low-value care.

  • implementation science
  • health services research
  • patient-centred care
  • evaluation methodology
  • healthcare quality improvement

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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  • Twitter @GrimshawJeremy, @andreapatey, @moriahellen, @tijnkool

  • Funding This study was funded by Canadian Institutes of Health Research (Grant number: MYG-158642).

  • Competing interests EK serves as a clinical consultant for BIND Benefits Inc.; JMG holds a CIHR Tier 1 Canada Research Chair in Knowledge Transfer and Uptake and has a CIHR Foundation Grant (FDN-143269); WL is Chair of Choosing Wisely Canada.

  • Patient consent for publication Not required.

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

  • Data availability statement There are no data in this work.

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