De-implementation of low-value care: contrasting theories, models, and frameworks to generate methodological guidance

Low-value care remains pervasive across healthcare systems and consumes scarce resources while exposing patients to avoidable harms. De-implementation, the purposeful process of reducing, restricting, replacing, or discontinuing low-value practices, has gained momentum, yet the field still lacks clear methodological guidance grounded in theory. De-implementation is often treated as "reverse implementation", despite accumulating evidence that stopping practices can activate distinct mechanisms and constraints.

In this paper, we synthesize and contrast theories, process models, and frameworks relevant to de-implementation of low-value care to generate actionable methodological guidance. Drawing on a theory-informed narrative review and constant-comparative synthesis, we identify where de-implementation converges with implementation (e.g., staged processes; multilevel determinants; use of established determinant, strategy, and outcome frameworks) and where it diverges in ways that matter for design and evaluation. Across sources, three recurring lenses structure these divergences: (i) the psychology of stopping (habit disruption, loss aversion, cognitive biases, professional identity threats), (ii) multi-level constraints and politics (incentives, regulation, professional norms, stakeholder interests), and (iii) the nature of the low-value practice and endpoint (reduction vs. restriction vs. elimination; replacement vs. disenchantment discontinuance). We translate these contrasts into ten streamlined methodological recommendations that specify what investigators should state and report in practice, including configuration (stand-alone vs. embedded/paired), low-value classification, explicit determinant-to-strategy-to-mechanism logic, inclusion of patient experience and unintended consequences, and dual-trajectory evaluation when substitution is involved.

De-implementation is not simply implementation in reverse. Methodological rigor in de-implementation research requires explicitly specifying configuration and endpoint, aligning strategies with stopping-specific mechanisms and multilevel constraints, and evaluating beyond utilization to include mechanisms, patient experience, equity-relevant impacts, and unintended consequences. This paper provides a practical, theory-grounded set of recommendations to strengthen the design, evaluation, and reporting of future de-implementation studies.