Promoting Health Equity through De-Implementation Research

Abstract

 Ensuring equitable access to quality health care historically has focused on gaps in care, where patients fail to receive the high-value care that will benefit them, something termed unde­ruse. But providing high-quality health care sometimes requires reducing low-value care that delivers no benefit or where known harms outweigh expected benefits. These situations represent health care overuse. The process involved in reducing low-value care is known as de-implementation. In this article, we argue that de-implementation is critical for advanc­ing equity for several reasons. First, medical overuse is associated with patient race, ethnic­ity, and socioeconomic status. In some cases, the result is even double jeopardy, where racial and ethnic minorities are at higher risk of both overuse and underuse. In these cases, more tra­ditional efforts focused exclusively on underuse ignore half of the problem. Second, overuse of preventive care and screening is often greater for more socioeconomically advantaged pa­tients. Within insured populations, this means more socioeconomically disadvantaged pa­tients subsidize overuse. Finally, racial and eth­nic minorities may have different experiences of overuse than Whites in the United States. This may make efforts to de-implement over­use particularly fraught. We therefore provide several actions for closing current research gaps, including: adding subgroup analyses in studies of medical overuse; specifying and measuring potential mechanisms related to equity (eg, double jeopardy vs thermostat models of over­use); and testing de-implementation strategies that may mitigate bias.Ethn Dis. 2019;29(Suppl 1):93-96; doi:10.18865/ed.29.S1.93.