184 Chapter 6 Effectiveness of de-implementation strategies (meta-analysis) of controlled studies The effectiveness of de-implementation strategies to reduce low-value nursing procedures is only assessed for the controlled studies. Twelve of the fifteen controlled studies were eligible for inclusion in the meta-analyses [38-42, 44-47, 49, 50, 52]. Two controlled studies were excluded after no response of the author after sending a request for missing data [48, 51], and one study was excluded because the volume of low-value nursing procedures was not measured at patient level [43]. The relative risk ratio for the use of low value nursing procedures for all 12 studies was 0.95 [95% CI 0.80, 1.13]. Considerable heterogeneity was present in the effect estimate (I2 = 89%) (figure 3). Subgroup analyses could only be performed for type of design (figure 3). A subgroup analysis for type of de-implementation strategy could not be performed due to a lack of studies with the same strategy. Also a subgroup analyses for single vs. multifaceted strategies could not be performed due to a lack of studies with a single component strategy. A subgroup analyses for type of low-value care could not be performed due to a lack of studies assessing de-implementation strategies to reduce types of low-value nursing procedures other than restraint use. Subgroup analyses for the type of design of the studies (RCT, Cluster RCT, and controlled studies) showed no statistically significant subgroup effect (χ2 = 3.26, p=0.20), a moderate level of heterogeneity between the studies (I2= 39%), and a high level of heterogeneity within the subgroups (RCT= 92%, Cluster RCT= 71%, controlled studies= 96%) (figure 3). Based on the funnel plots we suggest that there is no publication bias (figure 4).
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