165 Effects of de-implementation strategies aimed at reducing low-value nursing procedures 6 was scored with low, high or unclear risk. The NOS consists of three categories: a) selection, b) comparability and c) outcome. A certain number of stars could be given for each category, resulting in a score of good, fair or poor quality of the studies. Disagreements in the risk of bias scoring was resolved by consensus or by discussion with a third researcher (TR, LvB, DS). Statistical analyses To summarize the overall evidence of de-implementation strategies aiming to reduce low-value nursing procedures in a descriptive and narrative synthesis, the data from all included studies was extracted in Microsoft Access (version 2016) and analyzed in Microsoft Excel (version 2016). The synthesis is performed separately for controlled and uncontrolled studies to reduce the risk of selection bias. To assess the effectiveness of deimplementation strategies to reduce low-value nursing procedures data of the controlled studies on the use of low-value care was analyzed in Review Manager 5.3. Data about the use of low value nursing procedures was pooled using a random effects model of Mantel-Haenszel [24], and risk ratios were calculated with 95% confidence intervals. The I2 statistics of Higgins [25] was used to measure heterogeneity between the included studies, which can be interpreted as the percentage of the total variability in a set of effect sizes between trials in a meta-analysis. When the I2 was 50% or higher we considered the results as a moderate or high level of heterogeneity [25]. If heterogeneity was present, subgroup analyses were performed. Subgroup analyses were performed by design of the study (RCT, Cluster RCT, and controlled studies), type of low-value care, and type of de-implementation strategy (single versus multifaceted, and type of strategy). Subgroup analyses by type of design were performed because failure to use adequately concealed random allocation can distort the apparent effects of care in either direction (26). Subgroup analyses for type of low-value nursing procedure were performed because the characteristics of the type of low-value nursing procedure that needs to be de-implemented (including underlying evidence, advantages of practice, credibility, attractiveness, feasibility) could be of influence on the effectiveness of the de-implementation strategy. Subgroup analyses for type of de-implementation strategy (including single versus multifaceted strategies and type of strategy according to EPOC taxonomy) were performed since we wanted to learn which strategy is most effective. A subgroup for type of design, low-value nursing procedure or de-implementation strategy was only performed when at least two studies with respectively the same design, low-value nursing procedure or de-implementation strategy could be included in each subgroup. Finally, sensitivity analyses for the subgroups were performed without studies with a high-risk score on 3 or more risk of bias criteria of the EPOC tool. Funnel plots were created to assess the publication bias.
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