164 Chapter 6 • Setting: hospitals, nursing homes, long-term care facilities and community settings. • Outcome: the study had to report on the effect of the de-implementation strategy on the volume of low-value nursing procedures. Case studies of individual patients, letters and editorials were excluded. Controlled studies were included in the meta-analysis if they reported data on the change in volume of low-value nursing procedures or if this data was available to the researchers after sending a request to the authors of the included paper. Data extraction Data of the included studies was extracted in a standardized data extraction form in Microsoft Access (version 2016) by one researcher (TR or AB). A second researcher (TR, AB, or DS) independently checked the extracted data. Any discrepancy was resolved by discussion between the researchers until consensus was reached. If this was not possible, a third researcher (LvB) made a judgement on the data entered. The following information was collected from all included studies: country of origin, design, setting, location of care, type of low-value nursing procedure, de-implementation strategy based on barrier assessment, de-implementation strategies, participants, reimbursement and funding, primary and secondary outcomes. The primary outcome was the change in volume of the low-value nursing procedure. The secondary outcomes were: adherence to the de-implementation strategy, changes in patient outcomes (e.g. pain), changes in patient satisfaction with care, changes in costs due to de-implementation of low-value nursing procedures, and changes in costs of the delivery of care. Authors of the included studies were contacted when more information was needed about unreported or missing data, and about the bias issues. If they did not respond, we sent a reminder after two to six weeks. We used the ‘Cochrane Effective Practice and Organisation of Care’ (EPOC) taxonomy [21] to categorize the different types of de-implementation strategies. The EPOC taxonomy includes four categories of strategies: a) delivery arrangements, b) financial arrangements, c) governance arrangements, and d) implementation strategies. The quality of the studies was assessed by using two risk of bias tools by two independent researchers (TR, AB, or DS). The Cochrane Effective Practice and Organisation of Care (EPOC) [22] was used for studies with a separate control group (randomized trails, and controlled before-after studies), and the Newcastle-Ottawa Scale (NOS) [23] was used for uncontrolled studies. The EPOC tool consists of nine suggested risk of bias criteria: random sequence generation, allocation concealment, baseline outcome measurements similar, baseline characteristics similar, incomplete outcome data, knowledge of the allocated interventions adequately prevented during the study, protection against contamination, selective outcome reporting and other risks of bias. Every criterion
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