LAUSR

D espite spending nearly twice as much on health care as other high-income countries, the United States falls behind in multiple metrics of population-health outcomes. As a result, there is an urgent need to prioritize value in medicine. A key component to this equation is the elimination of low-value services. Currently, the United States spends >$100 billion annually on overtreatment through unnecessary medical tests, treatments, and procedures that expose patients to harms without improving survival. Recognizing this, a number of surgical societies have partnered with the national Choosing Wisely campaign to generate >110 recommendations to avoid low-value care in surgery, including 24 surgical procedures. Although these recommendations are useful in identifying low-value surgical and perioperative care, they do not provide guidance on how providers or organizations can achieve de-implementation. De-implementation is the science of identifying factors that facilitate persistent use of low-value services to develop evidencebased strategies to eliminate these practices. To date, most efforts to reduce overtreatment have focused on unnecessary diagnostic testing or medications which are more easily addressed with interventions such as ordering restrictions, market withdrawals, or changes in insurance coverage. De-implementation of low-value surgical procedures may require unique considerations due to direct financial incentives to do more irrespective of value, a need to maintain surgeon discretion in the operating room, and more entrenched practices before efficacy data are available. Although some lowvalue procedures are naturally de-implemented (eg, laparoscopic adjustable gastric band surgery after introduction of sleeve gastrectomy), others continue to be performed at high rates (eg, screening colonoscopy for patients with limited life expectancies). This underscores the importance of developing effective strategies to achieve de-implementation to reduce cost and harms from lowvalue services. Most successful attempts at de-implementation require multifaceted and multilevel strategies. Multifaceted strategies target de-implementation through a combination of interventions and are likely more effective than single component strategies. For example, a potential provider-facing multifaceted strategy to reduce unindicated antibiotic prescribing might be to educate clinicians on national recommendations and audit and provide feedback on individual