Table 2 Barriers and Facilitators to HTR, Disinvestment, De-implementation, and De-adoption (*Barriers specific to implementation of HTR recommendations)

Climate and Context

Individual’s negative attitudes, overall sense of political will, and openness to research

Health Care Providers

Physicians are reluctant to dismiss outmoded devices and procedures [4]

Lack of incentives to decrease or remove technologies [22]

Use of clinical champions [5]

Involve clinicians to increase buy-in [2]

Address perceived net benefit to patients [8]

Patients/Public

Removal of technologies and procedures may cause concern for health professionals and patients who will view the exercise as a reduction of available health services [22]

Shared dialogue [21]

Political/Social/Decision makers

Political and social barriers/push back [2, 19, 22]

Absence of political drive [21]

Lack of support from decision makers [20]*

Lack of collaboration [19, 21]

Political support [5, 21]

Government interest [2]

Local/national relationships [5]

Policy regulations and restrictions [3, 8]

Encouragement of political discussion and raising awareness before and during implementation [20]*

Linkage and Exchange

Underlying linkage and exchange between researchers and knowledge users, policy makers and stakeholders

Lack of a well-planned implementation strategy that involves all stakeholders and is aligned with the initial goal of the program [20]*

Absence of strong leadership [20]*

Concept of low-value care not understood [24]

Cost savings viewed as unfavourable [24]

Broad and early stakeholder engagement [2, 20]

Meaningful stakeholder engagement and on-going knowledge exchange [3]

A dissemination strategy tailored to target groups [20]*

Consideration of local contexts [20]*

Use of clinical champions [5]

Address perceived net benefit to patients [8]

Public representatives involvement in the process to increase knowledge of the HTR process [2]

Shared dialogue [21]

Do not frame as ‘waste’ but focus more on ‘harm’ and staged testing and treatment [25]

Coordination/collaboration/professional understanding [5, 21]

Research Evidence, a Structured HTR Process, and Resources

Timeliness, relevance and local applicability of research

Lack of methods to identify technologies with uncertain cost-effectiveness [19]

Lack of understanding and expertise of HTR [2, 19, 21]

Lack of approaches to conduct a HTR that are transparent [21]

Lack of relevant evidence of the technology itself [18, 19]

A structured evidence-based process that includes transparent methods for identification, prioritization, and assessment of ineffective health technologies [20]*

Good evidence base for identification and recommendations [20]*

Mitigate with clear identification and prioritization criteria [7, 10]

Additional human and financial resources for sustainable implementation [20]*

Role of Researchers and HTR

The role of researchers to facilitate the transfer of research which includes views of their own role, communication skills, and packaging of the research results

Researchers may not understand their role

Financial resources for HTR [20]

Lack of resources and human resources to support HTR [19, 20]*

Large investment in work and time required for HTR [19, 21]

Difficulty in communicating with a variety of audiences and public perceptions [2, 5]

Capacity building in KT and change management [1]

Understanding KT theories, models and frameworks and use of effective and multifaceted KT interventions [1]

Development of a KT strategy to ensure uptake of HTR recommendations ([20, 22]

Role of Stakeholders, Knowledge Users and the Health System in HTR

Skills and expertise

Lack of skills [2]

Lack of resources and human resources to support HTR [19,20,21]*

Absence of strong leadership [20]*

Raising awareness and leadership at all levels [1, 20]

Use of change agents or knowledge brokers [12]

Decision makers need to understand the HTR process and provide support