REVIEW

CURRENT
OPINION Deadoption of low-value practices in the ICU
Christopher M. Fung a and Robert C. Hyzy b

Purpose of review
Change of practice in the ICU, particularly the discontinuation of approaches, which are no longer felt to
be beneficial, can be challenging. This review will examine this issue and outline current thinking
regarding how to best approach it.
Recent findings
Practices in medicine that do not provide patients benefit and possibly cause harm exist throughout
medicine and are called low-value practices. Some low-value practices have successfully been removed
from the ICU whereas others remain. The process of removing these practices from established care is often
called deadoption. Low-value practices that are simply ineffective but produce comparatively less harm or
cost, may represent a significant challenge to deadoption. Additionally, although no single intervention has
been identified as the preferred method of deadoption of a low-value practice, we advocate for a
multimodal approach.
Summary
Deadoption in the intensive care unit of practices that either cause harm or are significantly costly relative
to their benefit remains an elusive goal. Attempts at deadoption should target local ICU circumstances,
while still encompassing the spectrum of care outside the ICU, engage nursing more fully, promote the use
of local champions, especially peers, and recognize the requirement to seek sustainability.
Keywords
Choosing Wisely, deadoption, ICU, low-value practices

INTRODUCTION including de-implementation, reallocation, disin-

Low-value practices in medicine can be defined as
therapies and diagnostic tests that have been found
to be ineffective or potentially harmful. In a sense,
the newer use of the term deadoption really reflects
medical progress, as newer therapies felt to be effec-
tively displace older practices. Examples of these
practices, the study of their efficacy, and subsequent
removal from the body of medical practice when
found to be of low-value is as old as medicine itself
[1,2]. However, where some low-value practices, such
as the use of activated protein C in severe sepsis are
&&
rapidly removed [3 ] from clinical practice when
contradictory evidence is found, others, such as the
use of the pulmonary artery catheter seem to span
generations of practitioners [4]. The study of why
some low-value practices fade quickly from use and
others persist is a nascent area of investigation within
implementation science known as deadoption [5].
CONTRASTING PATTERNS OF
DEADOPTION IN THE ICU
The deadoption of established practices has been
branded with a variety of different terminologies
vestment, and others among 43 different terms
identified by Niven et al. [6]. In the ICU, the
team-based approach to care given there and the
multisystem disease present among ICU patients
presents a unique set of challenges for the dead-
option of established practices. Deadoption is espe-
cially important in critical care given the high
clinical stakes coupled with the high monetary costs
of delivering care in the modern ICU.
In the ICU, patterns of deadoption vary, such as
has been seen with the pulmonary artery catheter
(PAC) and routine stress ulcer prophylaxis (SUP).
Both interventions were once and, in some places,
continue to be commonplace in both surgical and
a
Division of Emergency Critical Care, Department of Emergency Medi-
cine and bDivision of Pulmonary and Critical Care Medicine, Department
of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
Correspondence to Robert C. Hyzy, MD, Division of Pulmonary and
Critical Care Medicine, Department of Internal Medicine, University of
Michigan, 3916 Taubman Center, Ann Arbor, MI 48109, USA. E-mail:
rhyzy@umich.edu
Curr Opin Crit Care 2019, 25:517–522
DOI:10.1097/MCC.0000000000000644

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Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Critical care outcomes
KEY POINTS
 Deadoption is the process of removing a low-value
practice and varies widely in the ICU according to a
complex array of factors including cost and perceived
harm to the patient.
 Use of the pulmonary artery catheter was rapidly
deadopted whereas the routine use of stress ulcer
prophylaxis has remained relatively widespread despite
newer evidence suggesting a lack of benefit.
 The Choosing Wisely Campaign in the ICU was one
national attempt at deadoption. However, the success
of this effort has been difficult to establish.
 The rise of bundled payments and other incentive-
based, alternative payment methods would likely
enhance deadoption of some care practices if
integrated with national initiatives, such as Choosing
Wisely and recommendations of multispecialty
professional societies.
medical ICUs. Born of data in the 1970s and 1980s
[7–9], the PAC was rapidly deadopted whereas rou-
tine SUP continues to persist. Although PAC use
took decades to become commonplace, eventually
becoming utilized in up to 40% of all ICU patients
[4], its adoption had not been based on studies
demonstrating patient-centered benefit but instead
a belief that more available information inherently
conveyed benefit. Although early doubters were
labeled iconoclasts [10], evidence began to emerge
suggesting harm rather than benefit [11]. However,
it was not until several well designed randomized,
clinical trials were published that demonstrated a
lack of benefit to PAC use that deadoption occurred
[12]. Nevertheless, when deadoption occurred it did
so rapidly [13,14]. Although the reasons for rapid
deadoption of the PAC are speculative, the juxtapo-
sition of solid research evidence with a cumbersome
and sometimes dangerous procedure resulting in
little material gain for clinicians appeared sufficient
to counteract the bias that more information is
inherently good.
The routine use of SUP in critically ill patients
began after bleeding from stress ulceration [7] had
been shown to decrease with SUP via antacid admin-
istration in a 100-patient RCT [8] and became rou-
tine practice during the subsequent decades as more
evidence suggested benefit [15]. Subsequently, stud-
ies demonstrated risks were associated with SUP,
including ventilator-associated pneumonia [16],
Clostridium difficile colitis [17], and interference with
other medicines [18]. Early challenges to SUP effi-
cacy went ignored. With the introduction of early
enteral feeding, the incidence of stress ulceration
518 www.co-criticalcare.com
Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.
seemingly declined [19]. Despite this SUP remained
routine and was often continued without indication
into the remainder of patients’ hospital courses,
presumably reflecting assumed benefit [20,21]. RCTs
conducted within the context of modern ICU prac-
tices have shown no benefit even among a popula-
tion of patients thought to be at risk for significant
stress ulceration [22,23]. Despite a new ‘epoch of
care’ ostensibly because of early enteral alimenta-
tion [24], clinicians continue to routinely prescribe
SUP even in those patients without risk factors on
the basis of a small but statistically significant risk of
bleeding. A survey of worldwide SUP practices of 97
ICUs in 11 mostly European (8 of 11) countries
demonstrated that 26% of ICUs in this group pre-
scribed SUP for all admitted patients, 19% contin-
ued SUP at ICU discharge and only 64% had a formal
guideline for usage of SUP [25]. Here, the presence of
strong evidence from randomized clinical trials has
thus far proven ineffective in promoting deadop-
tion, confirming the complexity, and poorly under-
stood nature of deadoption.
A medication whose risks are not immediate and
clearly linked in real-time is not a comparable inter-
vention to invasive hemodynamic monitoring
where complications can be dramatic and directly
observed to be related. Low-value practices in the
ICU represent a heterogenous group of medications,
procedures, and diagnostics within an even further
heterogenous population of patients, providers, and
hospitals. Outside of the ICU attempts have been
made to define a common framework for deadop-
tion that can be applied to any low-value practice
&&
[6,26 ]. Additional attempts have sought to identify
common barriers to deadoption [27]. A study by
Sauro et al. [28] examined barriers to deadoption
of a low-value practice, routine use of albumin for
resuscitation, and compared this with aspects of
adoption of a new high-value practice, low-molecu-
lar-weight heparin (LMWH) for VTE prophylaxis.
Using a mixed methods approach consisting of a
retrospective audit of usage data and cross-sectional
survey of ICU providers, the authors found high-
provider self-reported knowledge of and adherence
to best evidenced-based practices. Despite this, use
of LMWH for VTE prophylaxis occurred in only 38%
of admissions and more than 20% of patients
received albumin for resuscitation.
Interestingly, whenever barriers to changing
practices were characterized, similar profiles
emerged for both adoption of the high-value prac-
tice and deadoption of the low-value practice.
Reported barriers to both adoption and deadoption
among this survey of physicians, nurses, and phar-
macists included insufficient knowledge, ICU cul-
ture, ICU leaders with strong clinical preferences,
Volume 25  Number 5  October 2019
 Deadoption of low-value practices in the ICU Fung and Hyzy

issues with or absence of guidelines and perceived
lack of support from other job families [28]. Facili-
tators of practice change were also assessed and
various educational interventions, clinical cham-
pions, order set modification, and feedback systems
were all identified. Overall, clinical champions were
perceived as most helpful to implement best prac-
tices. Several hypotheses for potential empiric vali-
dation emerge from this work most notably:
deadoption and adoption of clinical practices suffer
from the same barriers; and practice culture modifi-
cation using site-based clinical champions offers the
most effective strategy for deadoption.
CHOOSING WISELY IN CRITICAL CARE
The Choosing Wisely Campaign, founded as an
effort by the American Board of Internal Medicine
Foundation to decrease the utilization of unneces-
sary medical interventions, was the culmination of a
decade of increasing awareness of low-value practi-
ces in medicine in both the medical and lay press
&&
[29,30 ]. The campaign debuted in 2012 and ini-
tially tasked each of nine medical specialty societies
to develop a top five list of low-value practices,
including tests, treatments, and other services
whose use should be reevaluated or discontinued
by clinicians. A group representing the American
Association of Critical Care Nurses, American Col-
lege of Chest Physicians, American Thoracic Society
and Society of Critical Care Medicine, issued the
Choosing Wisely top five list for critical care. This
list of low-value practices is listed in Table 1. It was
hoped that this campaign would bring about signif-
icant change in medical practice [31].
Five years after the debut of these recommen-
dations, limited data exist to demonstrate the effec-
tiveness of Choosing Wisely implementation in the
ICU. The Choosing Wisely Campaign itself has cited
several examples [32,33] most notably the reduction
in daily chest radiographies (CXRs). As a result of
ICU staff education, order set modification, and
data-driven EHR prompts at one institution, the
authors reported a reduction from approximately
one CXR per ventilator day to 0.3 and 0.6 in the MICU
and SICU, respectively [33]. In a second study, strate-
gies for deadoption of the daily chest X-ray in a MICU
and CVICU were compared [34]. Trumbo and col-
leagues found that an educational intervention con-
sisting of didactic teaching, peer coaching and weekly
feedback on X-ray ordering to providers resulted in a
decrease in chest X-rays ordered in their CVICU but
not the MICU. A third study examined the single,
simple intervention of an ICU medical director
requesting CXRs be ordered only on an on-demand,
indication-driven basis resulted in a decrease of CXR
ordering by about 0.2 per patient day [35], suggesting
site-based clinical champions are effective at promot-
ing deadoption. Each of these three studies attempted
to deadopt the same low-value practice (routine CXRs)
and each resulted in only a modest decrease in CXRs
during the study period after a deadoption interven-
tion occurred. In two of the studies [34,35], a gradual
increase in CXR ordering rates later occurred, suggest-
ing that issues of sustainability of deadoption merit
further consideration.
Trumbo and colleagues also performed a quali-
tative analysis of the intervention using the Consol-
idated Framework for Implementation Research
(CFIR); a widely cited structure for evaluating the
translation of new evidence into clinical practice
[36]. They were able to identify a variety of facili-
tators and barriers to deadoption of the daily CXR.
The use of peer champions and feedback on ordering
habits were determined to be major facilitators of
deadoption. Conversely, poor investment in change
because of frequently rotating providers, E-mail
fatigue, and ordering rationale based on expecta-
tions of attending provider were identified as bar-
riers. Whether peer champions might prove to be
more effective than supervisory champions is a
potential subject of further analysis. Interestingly,
when qualitatively evaluating the difference
between CVICU and MICU providers, these authors
report that MICU providers cited the availability of
alternate imaging modalities (bedside ultrasound) as
a factor in reducing CXR ordering. However, this
raises the possibility that rather than reducing

Table 1. The Choosing Wisely for Critical Care list

(1) Don’t order diagnostic tests at regular intervals (such as every day), but rather in response to specific clinical questions.
(2) Don’t transfuse red blood cells in hemodynamically stable, nonbleeding intensive care unit patients with a hemoglobin concentration
greater than 7 mg/dl.
(3) Don’t use parenteral nutrition in adequately nourished critically ill patients within the first 7 days of an intensive care unit stay.
(4) Don’t deeply sedate mechanically ventilated patients without a specific indication and without daily attempts to lighten sedation.
(5) Don’t continue life support for patients at high risk for death or severely impaired functional recovery without offering patients and their
families the alternative of care focused entirely on comfort.

Reproduced from Angus et al. [29].

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Critical care outcomes
unnecessary imaging, providers may be substituting
one measured modality for an unmeasured one.
Overall, these three studies examining the deadop-
tion of the routine CXR provide mixed results
regarding the efficacy of any one intervention or
group of interventions for reducing low-value prac-
tices. Until additional empiric research provides
insight it seems reasonable to suggest any interven-
tion to promote deadoption should be tailored to
individual circumstances, involve clinical cham-
pions and be cognizant of the requirement to seek
sustainability [37].
As a follow-up to Choosing Wisely in Critical
Care, the Critical Care Societies Collaborative
(CCSC) conducted a national survey of the members
of its constituent professional societies: The Ameri-
can Thoracic Society, The American Association of
Critical Care Nurses, The American College of Chest
Physicians and the Society of Critical Care Medicine
[38]. The authors reported approximately 87% of
physicians were aware of Choosing Wisely in Criti-
cal Care, compared with just 38% of nurses suggest-
ing increased awareness among nurses may be
required in order to make the recommendations
for deadoption more widespread. This survey also
identified multiple ongoing initiatives at respond-
ents’ institutions to implement the Choosing
Wisely in Critical Care recommendations including:
revision of order sets to reduce unnecessary trans-
fusions or diagnostic testing; development of poli-
cies related to each of the Choosing Wisely
recommendations; and providing continuing edu-
cation to all staff regarding Choosing Wisely. Each
of the original five Choosing Wisely in Critical Care
recommendations have long been identified as low-
value practices and efforts to deadopt them were in
place in many hospitals before the campaign
started. In the era of multidisciplinary critical care
rounds [39], enhanced engagement of ICU nursing
offers a potentially significant opportunity to fur-
ther the deadoption goals of Choosing Wisely in
Critical Care. Additionally, coupled with early data
from other specialties demonstrating the limited
efficacy of providing recommendations alone in a
population-level analysis [40], the CCSC survey data
suggest any new iteration of Choosing Wisely in
Critical Care should provide not only recommen-
dations but also a set of evidence-based interven-
tions to facilitate deadoption.
FINANCIAL IMPLICATION OF
DEADOPTION
Although financial incentives have long been used
to drive the adoption of new evidence-based prac-
tices, few examples of their use for deadoption of
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low-value practices exists. One example, the use of
drotrecogin alpha for severe sepsis, demonstrates
the power of financial incentives to drive both the
adoption and subsequent deadoption of care in the
ICU. The use of drotrecogin alpha (activated protein
C) in severe sepsis remained fairly low until after
Medicare incentivized its use in 2002 by initiating
add-on payments. After this incentive was removed
&&
in 2004, its use dropped sharply [3 ]. Prior to the
removal of the financial incentive, the Surviving
Sepsis Campaign had provided a weak recommen-
dation in favor of using drotecogin alpha in severe
sepsis. In this instance, the financial incentive miti-
gated the impact of a national guideline recommen-
dation, albeit a weak one.
Subsequent evidence refuting the efficacy of
drotecogin alpha began to accumulate, culminating
in a large RCT, which demonstrated both limited
efficacy and harm [41], causing its removal from the
market. Although financial incentives have been
tied to quality measures or guideline adherence in
other areas of medicine, to date no payer has directly
incentivized the deadoption of a low-value practice
in the ICU. Indirectly, bundled payments are likely
already providing financial incentive towards dead-
option of both costly or harmful practices, although
and this remains an active area of investigation.
Although the gradual decline in use after removal
of the Medicare incentive payment is likely because
of a multitude of contributing factors, it is unlikely
that drotrocogin alpha, an intervention both costly
and harmful, would have survived in the era of
bundled payments. Recently, CMS has introduced
the Bundled Payments for Care Improvement (BCPI)
initiative and data collected from healthcare sys-
tems that participate in BPCI will provide valuable
insights into their effect on low-value practices in
the ICU. Furthermore, as most bundled payment
models reward systems of care rather than individ-
ual performance, deadoption within the ICU will
require increasing partnership with both other spe-
cialties and other phases of care.
INTENSIVE CARE WITHOUT BORDERS
Critical care outcomes are often influenced by care
outside of the ICU. Although the CCSC included
both nursing and physician specialty groups a well
defined partnership with professional societies out-
side of the CCSC might be one avenue to further the
cause of deadoption of low-value ICU practices. For
example, a major area of improvement highlighted
by the original Choosing Wisely in Critical Care
recommendations was to decrease the use of deep
sedation in mechanically ventilated patients. Light
sedation is associated with improved outcomes [42].
Volume 25  Number 5  October 2019

Importantly, early light sedation within the first
48 h of hospitalization, inclusive of the emergency
department encounter for patients intubated
there, has been associated with lower hospital mor-
tality, lower frequency of delirium, and fewer
mechanical ventilation days [43,44]. Early deep
sedation in the emergency department has been
associated with higher mortality, ICU, and ventila-
tor days [43] and can propagate for days into the
ICU course leading to the phenomenon of sedation
overshoot [45].
These data suggest, in order to further reduce the
low value ICU practice of deep sedation, decreasing
the level of sedation once the patient arrives in the
ICU may not be sufficient to be impactful. Similarly,
in the post-ICU course, the practice of stress ulcer
prophylaxis is often continued even when the risk of
stress ulceration has subsided [25] and deadopting
its routine use in the ICU may have lasting benefits
in the post-ICU or post-discharge course.
Harmonizing recommendations regarding low-
value practices with groups not previously consid-
ered to be part of the continuum of ICU care, such as
professional societies from emergency medicine,
hospital medicine, and primary care might increase
the effect of those recommendations on both the
pre-ICU and post-ICU courses. The rise of bundled
payments will likely require partnership in reducing
low-value practices not only within the hospital but
also in other areas of postacute care, such as skilled
nursing facilities, in-home services, and other
outpatient settings.
CONCLUSION
The deadoption of ICU practices that either cause
harm or are significantly costly relative to their
benefit remains an elusive goal. To the extent that
deadoption practices make a poor substrate for per-
formance measures (unpublished ATS workshop
report by Artis et al. regarding performance measure
development using ARDS guidelines as an example),
learning more about how to change behavior to
promote deadoption remains as fertile territory for
implementation science. Although there have been
some successes, much work needs to be done to
better understand how to promote behavioral
change in the ICU in order to do less, not more.
Low-value practices that are simply ineffective but
produce comparatively less harm or cost, may rep-
resent a particularly daunting challenge to dead-
option. The rise of bundled payments and other
incentive-based, alternative payment methods
would likely enhance deadoption of some care
practices if integrated with national initiatives,
such as Choosing Wisely and recommendations of
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Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.
Deadoption of low-value practices in the ICU Fung and Hyzy
multispecialty professional societies. Future studies
may further elucidate the role of both bundled pay-
ments and other more targeted interventions aimed
at reducing low-value practices. Pending the further
elucidation of best practices, we believe attempts at
deadoption should target local ICU circumstances,
while still encompassing the spectrum of care out-
side the ICU, engage nursing more fully, promote
the use of local champions, especially peers, and
recognize the requirement to seek sustainability.
Acknowledgements
None.
Financial support and sponsorship
None.
Conflicts of interest
There are no conflicts of interest.
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Volume 25  Number 5  October 2019