LAUSR

Reducing medication overuse is what is known as a “wicked problem”—resistant to change and imbued with complex interdependencies that defy reductionist approaches. The Choosing Wisely campaign, while well-intended, has had limited success to date in curbing the excessive, unnecessary, and often inappropriate use of medications, especially among older adults who commonly experience such medication misadventures. Intensive programs have been more successful yet are difficult to scale. Two decades ago, health care looked to the aviation industry for lessons in the processes and cultures of safety. What is needed now for deimplementation is a similar transformational change in thinking. One of the most challenging aspects of deimplementation is stopping a recurrent treatment or test that the patient has been regularly receiving. It is one thing to counsel a patient that she does not need imaging for her low back pain, or to place barriers to ordering, accessing, or paying for this kind of service. It is another entirely to tell a patient to stop something they are used to receiving, for example a glucose-lowering medication or analgesic she has been taking for years. The administrative tools that can be used to restrict access often do not apply. Patients may feel abandoned. Both patients and clinicians may fear what will happen if they stop a treatment they have previously believed was necessary. Not rocking the boat spares both clinicians and patients the time and psychological distress of potentially hard conversations and decisions. It is in the face of these challenges that seeking insights from other fields may offer fresh opportunities for creating meaningful change. If we seek to modify behavior, who better to engage than experts in advertising, communications, economics, and political science, which concern themselves with understanding and influencing how people think and act. Meanwhile, within health care, the growing emphasis on implementation science provides a tremendous lever for offering practical tools supported by rigorous theory that can be used to create behavior change around deimplementation. A prime example is the COM-B model, which posits that behavior change arises from the interaction of capabilities (the knowledge, skills, and self-efficacy required to enact a behavior), opportunity (the physical and social environment that enables a behavior), and motivation (ingrained and purposeful drive to expend the effort to make a behavior happen). It is the combination of these three elements that is most likely to change behavior in the short term and sustain it over time. In isolation, each driver is less effective. Using this model can help us understand why many efforts to reduce overuse have had limited success. To gain these Received: 4 August 2021 Revised: 12 August 2021 Accepted: 14 August 2021