Limitations
This study has several important limitations. As a real-world, practical de-implementation trial, the study was bound to a particular time and place, and thus subject to the influence of larger environmental and system-level factors such as broader trends in decreasing opioid prescribing and the disruptions associated with the COVID-19 pandemic. These factors complicate interpretation, insofar as it is unclear if our findings regarding CDS would generalize to a context in which opioid prescribing trends were steadier in standard practice, or during periods of time when health services were not in a state of upheaval and reorganization. To some extent, these challenges are inherent to all implementation research. Conducting this study in a single large multi-clinic health system offered important advantages with respect to feasibility, but also may limit generalizability. While randomizing at the provider level has various advantages for implementation science, it can be difficult to achieve balance on all relevant provider characteristics. Another limitation is that utilization of the CDS was low among providers randomized to CDS or CDS-E arms. However, the study team made reasonable efforts to ensure that the CDS was easily accessible and that providers were aware of this resource. It is nonetheless possible that the training did not adequately address hesitancy among providers or sufficiently convey the utility of the CDS for informing discussions with patients. If providers did not consider the CDS to be of value in their prescribing decisions, it is possible that other strategies (e.g., training on the most recent prescribing guidelines, tailored feedback, etc.) would be more successful in changing practices. Future research should focus on ways to increase the perceived relevance of CDS resources for providers, and investigate other approaches to de-implementing potentially harmful practices.