What is known about this topic?

Healthcare professionals provide care to help patients; however, sometimes that care is of low value – at best ineffective and at worst harmful. Behavior substitution has been identified as a common technique for de-implementing behavior. The assumption that Behavior substitution may be inherently easier to apply than other techniques for de-implementation has not been tested empirically.

What does this article add?

We discuss why Behavior substitution may be a useful de-implementation strategy, and why it may not be suitable for all circumstances. We propose a list of principles that practitioners and researchers could consider when selecting an alternative behavior to replace the behavior being de-implemented. The principles proposed provide researchers with a comprehensive list of questions to consider when selecting substitute behaviors. Applying these principles to de-implementation interventions that include Behavior substitution may increase the likelihood that this technique will be effective in reducing low-value care.

Background

De-implementation initiatives have focused on reducing inappropriate healthcare.1 Conceptual frameworks about de-implementation provide systematic guidance for developing and evaluating de-implementation interventions.2 However, less attention has focused on identifying what strategies are best suited for de-implementation.

Behavior substitution, a behavior change technique whereby an unwanted behavior is replaced with a wanted behavior3 may be an effective strategy for de-implementation. It has been noted that Behavior substitution is a unique type of strategy for de-implementation, separate from removing or reducing a behavior, which requires minimum criteria for deciding when to use it.4,5 However, there has been little discussion about how to select substitute behaviors. In this article, we discuss why and when Behavior substitution may be a useful de-implementation strategy and why it may not be suitable for all circumstances. Finally, we propose a list of principles for selecting substitute behaviors, which should be considered when considering Behavior substitution as a de-implementation strategy.

A technique for de-implementing low-value care

A recent systematic review of de-implementation interventions found that Behavior substitution is commonly used to de-implement low-value care.6 One benefit of using Behavior substitution is that this strategy may be more acceptable to healthcare professionals (HCPs) than current ways to reduce low-value or harmful care, which may be more punitive and extreme (e.g. financial penalties, medical practice sanctions, or restrictive measures).7

Behavior substitution makes theoretical sense. It may be attractive for HCPs who are trained to be action-oriented and are uncomfortable with the option of appearing to do nothing during patient consultations or in response to patient need. HCPs who fail to act are more likely to experience regret and blame than those who acted ineffectively. Cognitive psychology research suggests that, when previous inactions led to negative outcomes, the negative consequences of continuing to do nothing can lead to greater regret than the negative consequences associated with doing something, called the ‘inaction effect’.8Behavior substitution also has a long history of being effective when used with positive reinforcement (i.e. providing a reward conditional on performance of the behavior), in the field of Applied Behavior Analysis.9,10

Potential challenges to using Behavior substitution

Despite the appeal of using Behavior substitution for de-implementation, it comes with a number of challenges. First, there do not appear to be established methods for selecting appropriate substitute behaviors. Researchers may intuitively or pragmatically select a behavior within each context, without articulating a rationale, resulting in no collective learning for identifying substitute behaviors. Alternatively, HCPs could individually decide what to do in place of the undesired behavior. For example, in a trial in which general practitioners were asked to reduce prescribing of antibiotics for patients with upper respiratory tract infections (URTI), instead of suggesting a substitute behavior, the target behavior was framed as ‘manage patients with URTI without prescribing an antibiotic’.11 The problem with this is that, by leaving the choice of substitute behavior vague, the clinician may perform other actions that are equally unnecessary and potentially harmful (e.g. ordering a chest x-ray to rule out pneumonia). Replacing the unwanted behavior with a different form of low-value care would not be helpful.

Behavior substitution may not be an appropriate solution for all low-value care. When there is no clear clinical behavior to substitute, it may not be helpful to ask HCPs do something else instead; this would only burden them with another behavior. An example is unnecessary test ordering. If there is no clear clinical behavior to substitute, HCPs may need to focus on the nontechnical function of the low-value behavior, such as patient reassurance. Otherwise, they may be less inclined to consider a redundant substitute behavior and continue providing the low-value care.

Using Behavior substitution with positive reinforcement10 may lead to unintended consequences of reducing other desirable behaviors by prioritizing the rewarded behavior. Nonincentivized clinical activities may not receive the same attention as incentivized activities.12 In the context of time constraints, when certain behaviors are rewarded, HCPs may inadvertently reduce the rate of performing unrewarded, but desirable, clinical behaviors. Hence, we suggest that reinforcement should be used with caution and the full range of potential consequences should be monitored.

Proposed principles for selecting substitute behaviors

To systematically specify substitute behaviors for de-implementation interventions, we propose six principles (Table 1), derived from the Theoretical Domains Framework (TDF) of behavior change.13 The principles provide a foundation for a priori selection of the most appropriate substitute behavior. It is not meant to be an exhaustive list as there may be unique contextual concerns in the clinical setting; rather it is a basis for addressing the more common issues that may occur. The principles proposed address 7 of the 12 domains in the TDF and may increase the likelihood the selected substitute behavior is performed.

Table 1 - Principles, with questions to consider and examples, for selecting a substitute behavior for de-implementation interventions Themes Principle (derived from TDF domain) Questions for practitioner/policymaker/researcher Example Evidence and rationale Identify a substitute behavior that has a clinical rationale or strong evidence base for its use (Knowledge, Memory attention and decision processes, Beliefs about consequences) Is there an evidence base that supports a different behavior to perform in place of the undesired behavior? Using intermittent auscultation instead of electronic fetal monitoring for fetal surveillance during labor is associated with decreased caesarean sections and instrumental births and may positively impact the pregnant person's coping strategies. Intermittent auscultation may be an acceptable alternative to continuous fetal monitoring Objective Identify a substitute behavior that serves the clinical objective (patient outcome) and serves the practical objective (e.g. satisfy the patient that they have been taken seriously; offer symptom relief) (Beliefs about consequences, Social influences, Memory, attention and decision processes) Are patient expectations and needs likely to be met by doing the substitute behavior? In the case of a patient with acute back pain, the HCP's outcome goal may be to reduce the patient's level of pain, whilst the behavioral goal may be to reduce the number of X-rays for acute low back pain. Instead of completing a requisition form for an X-ray, the physician may give the patient educational materials with symptom relief strategies Ease to explain Identify a substitute behavior that is easily explainable to patients (Beliefs about capabilities, Social influences, Beliefs about consequences) Is the HCP able to explain to the patient why they are doing ‘x’ instead of ‘y’? Providing a viral prescription, which is similar in format to a drug prescription, except it explains the symptoms of an upper respiratory tract infection (e.g. common cold) and also provides management strategies instead of prescribing antibiotics for sore throat, will address the patient's concern and validate their illness, whilst eliminating the use of antibiotics Time Identify a substitute behavior that is no more time-consuming than the undesired behavior (Environmental context and resources, Beliefs about consequences) Will the substitute behavior take up more time for the HCP; will they have to neglect other duties? An alternative to order red blood cells (RBC) transfusion for patients with anemia in hospital is to order intravenous iron transfusions, which will likely take a similar amount of time as ordering RBC transfusion. The patient will still require the same level of monitoring, the ordering process is similar, and the HCP will follow similar duties Fit with skills Identify a substitute behavior that has good fit with existing skills (Skills, Beliefs about capabilities) Will HCPs have to learn a new skillset, or do they already have the skills necessary to perform the substitute behavior? Ordering intravenous iron instead of ordering RBC transfusion will likely require a skillset the HCP already has – involving the action of identifying anemia in a patient and ordering, which are the same skills used when ordering an RBC transfusion. Therefore, the HCP is not required to learn new techniques Cost Identify a substitute behavior that is no more expensive to perform than the undesired behavior (Environmental context and resources, Beliefs about consequences) Will the organization accrue extra costs for the HCP to perform the substitute behavior? For patients with anemia in hospital, ordering intravenous iron transfusions as an alternative to red blood cell transfusions can not only reduce unnecessary red blood cell unit transfusion, but also reduces hospitalization, re-transfusion, length of stay and costs. These factors may be appealing to a hospital organization as they target patient safety and likely reduce cost

HCP, health care professional; TDF, Theoretical Domains Framework.

First, the substitute behavior should have a strong evidence-based or clinical rationale. The evidence should suggest that the substitute behavior achieves better or equivalent patient outcomes than the undesirable behavior. If the proposed substitute behavior is neutral in its clinical effectiveness, it still may not be the best behavior to use because it potentially involves replacing one low-value care behavior with another low-value care behavior.

The substitute behavior should serve both the clinical objective and practical objective. It may be beneficial to frame the change in behavior on the outcome goal (what the behavior is likely to achieve, e.g. validate patient concerns, signaling the end of a consultation) rather than the behavior goal (e.g. decreasing the original behavior), but this is likely to be context-specific. The substitute behavior should also share some of the superficial attributes of the original behavior (e.g. giving the patient an item, such as a leaflet that suggests strategies for symptom management). Consequently, the patient will recognize this new behavior as having the same ‘social’ or nontechnical function as the original behavior.

The substitute behavior should be easily explainable to patients. HCPs may have to consider that the patient's goal may be different from their own goals. The patient's goal may be to be certain that their concerns are being acknowledged and addressed appropriately. Providing a tangible object (e.g. leaflet), explaining symptoms, and providing management strategies can address the patient's concern and validate their illness, whilst eliminating the use of low-value care. Additionally, if the patient has had experience of previous low-value care, they may be uncertain why the HCP is doing something different. Having an easily accessible explanation (e.g. informal ‘script’ to explain the rationale for a different approach that is acceptable to patients) would be helpful in maintaining a positive clinician–patient relationship.

The substitute behavior should be no more time-consuming to perform than the undesired behavior. The perceived time-consuming nature of a substitute behavior may lead HCPs to think they may have to neglect other tasks that are critical in the delivery of care.

A fifth point to consider is that the substitute behavior should have a good fit with existing skills. Substitute behaviors that align with HCPs’ current skillsets would have a greater likelihood of uptake, because the HCP would not have the burden of learning new skills.

From a systems perspective, a substitute behavior should be no more expensive to perform than the undesired behavior. Healthcare systems continue to try to balance cost efficiencies whilst maintaining high-quality care. Clinical practices that improve quality of care and are on par with current practice may be appealing to the administrators. If substitute behavior cost is higher than the undesired behavior, and the outcomes are similar, organizations may maintain the status quo.

Conclusion

In order to prevent the continued use of ineffective and harmful healthcare practices, effective strategies for de-implementation are needed. Behavior substitution may have practical and theoretical advantages for de-implementing low-value care but requires empirical testing. However, testing without guidance about what substitute behavior to use may be premature. The six principles we propose include a comprehensive list of questions to consider, increasing the likelihood of appropriate application of Behavior substitution, improving the care that patients receive, and advancing the science of de-implementation.

Acknowledgements

The views expressed in this article are those of the authors and may not be shared by the funding body. We would like to thank Dr Catherine Hurt for guidance, support, and supervision throughout the doctoral project. We would also like to thank Dr Justin Presseau and Dr Khara Sauro for comments on earlier drafts of this article.

Funding: this manuscript was part of a doctoral program of research (A.M.P.), funded by City, University of London Doctoral Scholarship. J.M.G. holds a Canada Research Chair in Health Knowledge Transfer and Uptake.

Authors’ contributions: A.M.P. conceived the commentary, under the supervision of J.J.F. and J.M.G. A.M.P. wrote the manuscript and the authors commented on the sequential drafts of the article. All authors reviewed and agreed upon the final manuscript.

Conflicts of interest

There are no conflicts of interests.

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