Table.

Forces Contributing to Deimplementation in Pediatrics

Theme	Underlying factor	Example of underlying factor	Example of deimplementation
Decreased prevalence of disease	Vaccinations	Haemophilus influenzae type b vaccine Streptococcus pneumoniae conjugate vaccine	Fewer lumbar punctures recommended in the evaluation of febrile infants and in simple febrile seizures
	Public health campaigns	Universal screening and treatment of group B streptococcus in pregnant women	Risk-based rather than universal laboratory testing and antibiotics for neonates born to febrile mothers
		Treatment of latent and active tuberculosis	Risk-based rather than universal tuberculosis screening in children
Evidence-based care	Criteria to evaluate evidence	Grading of Recommendations Assessment, Development and Evaluation	Routine urinalyses not recommended for asymptomatic children at well-child visits Computed tomography scans for head injury is limited through use of PECARN criteria Cervical cancer screening not recommended for patients younger than 21 y Corticosteroids and bronchodilators not recommended for bronchiolitis Blood tests not recommended in the evaluation of simple febrile seizure
	Organizations to synthesize evidence	US Preventive Services Task Force Cochrane Collaboration American Academy of Pediatrics
	Growing evidence base	Databases (eg, Pediatric Health Information System) Research consortiums  Clinical setting (eg, PECARN)  Age based (eg, Better Outcomes for Newborns through Research) Managed care organizations (eg, Kaiser Permanente)
	Ability to conduct high-quality randomized clinical trials	Improved public and private funding
Recognition of the harms of overuse	Overdiagnosis, overtreatment, and opportunity costs of overuse	Choosing Wisely initiative Lown Institute Journal of Hospital Medicine’s Things We Do For No Reason section Hospital Pediatrics’ Bending the Value Curve section	Neuroimaging not recommended in the evaluation of simple febrile seizure

Abbreviation: PECARN, Pediatric Emergency Care Applied Research Network.