170 Chapter 6 Study characteristics Uncontrolled studies Twelve of the 27 studies (44%) [9, 27-37] had an uncontrolled before-after design (table 2a). Of these twelve studies, six focused their intervention on reducing restraint use [9, 28, 29, 31, 32, 34], three on reducing inappropriate antibiotic prescribing [30, 33, 37], two on reducing time of indwelling urinary catheters [27, 36], and one on reducing unnecessary liver function tests [35]. The de-implementation strategy used within the uncontrolled studies were directed at nursing staff working in a hospital (n=10) [9, 27-32, 34-36] and in an urgent care center (n=2) [33, 37]. Most of the uncontrolled studies had a single center design (n=9) and were performed in North America (n=9) [9, 27, 28, 30, 32-34, 36, 37]. Most uncontrolled studies did not report on the characteristics of the patients and/or on the characteristics of the healthcare providers. Four uncontrolled studies (33%) have not clearly described the duration of the intervention [37, 38, 48, 50]. For the uncontrolled studies that mentioned the duration of the intervention it differed from 2 to 14 months. The follow up time after de-implementation of the studies that reported these results differed from 1 month follow up till 12 months. Controlled studies Fifteen of the 27 studies (56%) had a controlled design, including three RCTs (11%), seven cluster RCTs (26%) and five controlled before-after designs (19%) (table 2b). Of the controlled studies, fourteen studies focused their intervention on reducing restraint use [39-52], and one on reducing inappropriate antipsychotic prescribing [38]. The deimplementation strategy used within the controlled studies were directed at nursing staff working in a nursing home (n=10) [38, 39, 41, 42, 44-47, 51, 52], in a hospital (n=4) [40, 43, 48, 49], and in a residential care facility (n=1) [50]. Most of the controlled studies had a multicenter design (n=12) and were performed in Europe (n=9). Not all controlled studies reported on the patients’ characteristics and/or on the characteristics of the healthcare providers. Three controlled studies (20%) have not clearly described the duration of the intervention [27, 31, 39]. For the controlled studies that mentioned the duration of the intervention it differed from 1 to 12 months. The follow up time after de-implementation of the studies that reported these results differed from no follow up till 24 months. Strategies to reduce low-value care Uncontrolled studies The de-implementation strategies of six uncontrolled studies resulted in a positive significant effect on the volume of low-value nursing procedures (table 2a). The reduction in volume of low-value nursing procedure in the uncontrolled studies with a positive significant effect and with available data (n=5) ranged from 0.4% [34] reduction of low
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