A Health Systems Ethical Framework for De-Implementation in Health Care

Introduction: Unnecessary health care not only drive up costs, but also contribute to avoidable patient harms, underscoring an ethical obligation to eliminate practices which are harmful, lack evidence, and prevent spending on more beneficial services. To date, de-implementation ethics discussions have been limited and focused on clinical ethics principles. An analysis of de-implementation ethics in the broader context of the health care system is lacking. Methods: To better understand the ethical considerations of de-implementation, recognizing it as a health care systems issue, we applied Krubiner and Hyder's bioethical framework for health systems activity. We examine ethics principles relevant to de-implementation, which either call for or facilitate the reduction of low value surgery. Results and Discussion: From 11 health systems principles proposed by Krubiner and Hyder, we identified the 5 principles most pertinent to the topic of de-implementation: evidence and effectiveness, transparency and public engagement, efficiency, responsiveness, and collaboration. An analysis of de-implementation through the lens of these principles not only supports de-implementation but proves an obligation at the health system level to eliminate low value care. Recognizing the challenge of defining value, the proposed framework may increase the legitimacy and objectivity of de-implementation. Conclusions: While there is no single ideal ethical framework from which to approach de-implementation, a health systems framework allows for consideration of the systems-level factors impacting de-implementation. Framing de-implementation as a health systems is-sue with systems-wide ethical implications empowers providers to think about new ways to approach potential roadblocks to reducing low-value care. (C) 2021 Elsevier Inc. All rights reserved.

Automated summary

The study provides a comprehensive analysis of de-implementation ethics, emphasizing the obligation at the health system level to eliminate low-value care. By using a bioethical framework, it may increase the legitimacy and objectivity of de-implementation.