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Parvar SY, Mojgani P, Lankarani KB, Poursaeed F, Mohamadi Jahromi LS, Mishra V, Abbasi A, Shahabi S. Barriers and facilitators to reducing low-value care for the management of low back pain in Iran: a qualitative multi-professional study. BMC Public Health 2024; 24:204. [PMID: 38233835 PMCID: PMC10792884 DOI: 10.1186/s12889-023-17597-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2023] [Accepted: 12/27/2023] [Indexed: 01/19/2024] Open
Abstract
INTRODUCTION Low back pain (LBP) is a prevalent musculoskeletal disorder with a wide range of etiologies, ranging from self-limiting conditions to life-threatening diseases. Various modalities are available for the diagnosis and management of patients with LBP. However, many of these health services, known as low-value care (LVC), are unnecessary and impose undue financial costs on patients and health systems. The present study aimed to explore the perceptions of service providers regarding the facilitators and barriers to reducing LVC in the management of LBP in Iran. METHODS This qualitative descriptive study interviewed a total of 20 participants, including neurosurgeons, physiatrists, orthopedists, and physiotherapists, who were selected through purposive and snowball sampling strategies. The collected data were analyzed using the thematic content analysis approach. RESULTS Thirty-nine sub-themes, with 183 citations, were identified as barriers, and 31 sub-themes, with 120 citations, were defined as facilitators. Facilitators and barriers to reducing LVC for LBP, according to the interviewees, were categorized into five themes, including: (1) individual provider characteristics; (2) individual patient characteristics; (3) social context; (4) organizational context; and (5) economic and political context. The ten most commonly cited barriers included unrealistic tariffs, provider-induced demand, patient distrust, insufficient time allocation, a lack of insurance coverage, a lack of a comprehensive referral system, a lack of teamwork, cultural challenges, a lack of awareness, and defensive medicine. Barriers such as adherence to clinical guidelines, improving the referral system, improving the cultural status of patients, and facilitators such as strengthening teamwork, developing an appropriate provider-patient relationship, improving the cultural status of the public, motivating the patients, considering an individualized approach, establishing a desirable payment mechanism, and raising the medical tariffs were most repeatedly stated by participants. CONCLUSION This study has pointed out a great number of barriers and facilitators that shape the provision of LVC in the management of LBP in Iran. Therefore, it is essential for relevant stakeholders to consider these findings in order to de-implement LVC interventions in the process of LBP management.
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Affiliation(s)
- Seyedeh Yasamin Parvar
- Health Policy Research Center, Institute of Health, Shiraz University of Medical Sciences, Shiraz, Iran
- Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Parviz Mojgani
- Iran-Helal Institute of Applied Science and Technology, Tehran, Iran
- Research Center for Emergency and Disaster Resilience, Red Crescent Society of The Islamic Republic of Iran, Tehran, Iran
| | - Kamran Bagheri Lankarani
- Health Policy Research Center, Institute of Health, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Fereshteh Poursaeed
- Transitional Doctor of Physical Therapy Program, College of Professional Studies, Northeastern University, Boston, USA
| | - Leila Sadat Mohamadi Jahromi
- Department of Physical Medicine and Rehabilitation, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Vinaytosh Mishra
- College of Healthcare Management and Economics, Gulf Medical University, Ajman, UAE
| | - Alireza Abbasi
- Health Policy Research Center, Institute of Health, Shiraz University of Medical Sciences, Shiraz, Iran
- Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Saeed Shahabi
- Health Policy Research Center, Institute of Health, Shiraz University of Medical Sciences, Shiraz, Iran.
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Fournier KA, Dwyer PA, Vessey JA. De-adopting low-value care: The missing step in evidence-based practice? J Pediatr Nurs 2023; 69:71-76. [PMID: 36669294 DOI: 10.1016/j.pedn.2022.12.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Accepted: 12/20/2022] [Indexed: 01/19/2023]
Abstract
BACKGROUND Low-value care provides little or no benefit to pediatric patients, has the potential to cause harm, waste healthcare resources, and increase healthcare costs. Nursing has a responsibility to identify and de-adopt low-value practices to help promote quality care. PURPOSE 1) Describe the process of identifying and de-adopting low-value clinical practices guided by a conceptual model using a case study approach. 2) Identify facilitators and barriers to de-adoption practices, including levels of stakeholder engagement, organizational structures, and the quality of available scientific and non-scientific evidence. METHODOLOGY An evidence-based practice (EBP) project investigating the efficacy of antihistamines in decreasing infusion reactions to infliximab identified a low-value practice within a pediatric infusion center. The Synthesis Model for the Process of De-adoption was then applied to guide the de-adoption of this low-value practice. Case study analysis highlighted facilitators and barriers to de-adoption efforts. CONCLUSIONS The process for de-adopting care is an essential component of EBP and, as such, should be explicated through robust, standardized EBP processes and education. PRACTICE IMPLICATIONS Nurses are best positioned to identify, assess and prioritize low-value practices and facilitate the de-adoption of low-value practice that impact pediatric patients and families. Models to support de-adoption and a focus on site-specific practices including a prepared nursing workforce, continuous evaluation of care processes and the use of resources to assess for contextual determinants facilitates success and sustainability of this essential EBP approach.
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Affiliation(s)
| | - Patricia A Dwyer
- Satellite Services, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA.
| | - Judith A Vessey
- Medical, Surgical, & Behavioral Health Programs, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA.
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Baungaard N, Skovvang PL, Assing Hvidt E, Gerbild H, Kirstine Andersen M, Lykkegaard J. How defensive medicine is defined in European medical literature: a systematic review. BMJ Open 2022; 12:e057169. [PMID: 35058268 PMCID: PMC8783809 DOI: 10.1136/bmjopen-2021-057169] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVES Defensive medicine has originally been defined as motivated by fear of malpractice litigation. However, the term is frequently used in Europe where most countries have a no-fault malpractice system. The objectives of this systematic review were to explore the definition of the term 'defensive medicine' in European original medical literature and to identify the motives stated therein. DESIGN Systematic review. DATA SOURCES PubMed, Embase and Cochrane, 3 February 2020, with an updated search on 6 March 2021. METHODS Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses, we reviewed all European original peer-reviewed studies fully or partially investigating 'defensive medicine'. RESULTS We identified a total of 50 studies. First, we divided these into two categories: the first category consisting of studies defining defensive medicine by using a narrow definition and the second category comprising studies in which defensive medicine was defined using a broad definition. In 23 of the studies(46%), defensive medicine was defined narrowly as: health professionals' deviation from sound medical practice motivated by a wish to reduce exposure to malpractice litigation. In 27 studies (54%), a broad definition was applied adding … or other self-protective motives. These self-protective motives, different from fear of malpractice litigation, were grouped into four categories: fear of patient dissatisfaction, fear of overlooking a severe diagnosis, fear of negative publicity and unconscious defensive medicine. Studies applying the narrow and broad definitions of defensive medicine did not differ regarding publication year, country, medical specialty, research quality or number of citations. CONCLUSIONS In European research, the narrow definition of defensive medicine as exclusively motivated by fear of litigation is often broadened to include other self-protective motives. In order to compare results pertaining to defensive medicine across countries, future studies are recommended to specify whether they are using the narrow or broad definition of defensive medicine. PROSPERO REGISTRATION NUMBER CRD42020167215.
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Affiliation(s)
- Nathalie Baungaard
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Pia Ladeby Skovvang
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Elisabeth Assing Hvidt
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark
- Department for the Study of Culture, University of Southern Denmark, Odense, Denmark
| | - Helle Gerbild
- Health Sciences Research Centre, UCL University College, Odense, Denmark
- Faculty of Health Sciences, Oslo Metropolitan University, Oslo, Norway
| | - Merethe Kirstine Andersen
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Jesper Lykkegaard
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark
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Bermúdez-Tamayo C, Hernández MN, Alguacil J, Briones-Vozmediano E, Cantarero D, Portiño MC, Casino G, Santillán-García A, Calvente MDMG, Zapata LIG, Epstein D, Hernán M, García LP, Cantero MTR, Segura A, Zunzunegui MV, Juárez L, Miranda JJ, Mar J, Peiró R, Amez JG, Álvarez-Dardet C. Gaceta Sanitaria en 2019. Trabajando para mejorar la eficiencia en la publicación científica. GACETA SANITARIA 2021; 34:101-104. [PMID: 32151337 DOI: 10.1016/j.gaceta.2020.02.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- Clara Bermúdez-Tamayo
- Comité Editorial de Gaceta Sanitaria; Escuela Andaluza de Salud Pública, Granada, España; CIBER de Epidemiología y Salud Pública (CIBERESP), España.
| | - Miguel Negrín Hernández
- Comité Editorial de Gaceta Sanitaria; Departamento de Métodos Cuantitativos, Universidad de Las Palmas de Gran Canaria, Las Palmas, España
| | - Juan Alguacil
- Comité Editorial de Gaceta Sanitaria; Departamento de Sociología, Trabajo Social y Salud Pública, Universidad de Huelva, Huelva, España
| | - Erica Briones-Vozmediano
- Comité Editorial de Gaceta Sanitaria; Facultad de Enfermería y Fisioterapia, Universidad de Lleida, Lleida, España
| | - David Cantarero
- Comité Editorial de Gaceta Sanitaria; Departamento de Economía, Universidad de Cantabria, Santander, España
| | - Mercedes Carrasco Portiño
- Comité Editorial de Gaceta Sanitaria; Departamento de Obstetricia y Puericultura, Universidad de Concepción, Chile
| | - Gonzalo Casino
- Comité Editorial de Gaceta Sanitaria; Departamento de Comunicación, Universidad Pompeu Fabra, Barcelona, España
| | | | | | - Laura Inés González Zapata
- Comité Editorial de Gaceta Sanitaria; Escuela de Nutrición y Dietética, Universidad de Antioquia, Colombia
| | - David Epstein
- Comité Editorial de Gaceta Sanitaria; Departamento de Economía Aplicada, Universidad de Granada, Granada, España
| | - Mariano Hernán
- Comité Editorial de Gaceta Sanitaria; Escuela Andaluza de Salud Pública, Granada, España; CIBER de Epidemiología y Salud Pública (CIBERESP), España
| | - Leila Posenato García
- Comité Editorial de Gaceta Sanitaria; Instituto de Pesquisa Econômica Aplicada, Brasil
| | - María Teresa Ruiz Cantero
- Comité Editorial de Gaceta Sanitaria; CIBER de Epidemiología y Salud Pública (CIBERESP), España; Grupo de Investigación en Salud Pública, Universidad de Alicante, Alicante, España
| | - Andreu Segura
- Comité Editorial de Gaceta Sanitaria; Departamento de Ciencias Experimentales y de la Salud, Universidad Pompeu Fabra, Barcelona, España
| | - María Victoria Zunzunegui
- Comité Editorial de Gaceta Sanitaria; Departement de Médecine Sociale et Préventive, Université de Montréal, Montreal, Canada
| | - Lucero Juárez
- Comité Editorial de Gaceta Sanitaria; Universidad del Valle de México, Ciudad de México, México
| | - Juan Jaime Miranda
- Comité Editorial de Gaceta Sanitaria; Departamento de Medicina, Universidad Peruana Cayetano Heredia, Lima, Perú
| | - Javier Mar
- Comité Editorial de Gaceta Sanitaria; Vocal SESPAS de Gaceta Sanitaria; Hospital Alto Deba, Arrasate (Gipuzkoa), España
| | - Rosana Peiró
- Comité Editorial de Gaceta Sanitaria; CIBER de Epidemiología y Salud Pública (CIBERESP), España; Coordinadora del Consejo Asesor de Gaceta Sanitaria; Fundación para el Fomento de la Investigación Sanitaria y Biomédica de la Comunitat Valenciana FISABIO-Salud Pública, Valencia, España
| | - Javier García Amez
- Comité Editorial de Gaceta Sanitaria; Departamento de Ciencias Jurídicas Básicas, Universidad de Oviedo, Oviedo, España
| | - Carlos Álvarez-Dardet
- Comité Editorial de Gaceta Sanitaria; CIBER de Epidemiología y Salud Pública (CIBERESP), España; Grupo de Investigación en Salud Pública, Universidad de Alicante, Alicante, España
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Osorio D, Zuriguel-Pérez E, Romea-Lecumberri S, Tiñena-Amorós M, Martínez-Muñoz M, Barba-Flores Á. Selecting and quantifying low-value nursing care in clinical practice: A questionnaire survey. J Clin Nurs 2019; 28:4053-4061. [PMID: 31287603 DOI: 10.1111/jocn.14989] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Revised: 06/11/2019] [Accepted: 06/30/2019] [Indexed: 01/13/2023]
Abstract
AIMS AND OBJECTIVES To evaluate the opinion of hospital nurses on a group of recommendations aimed at reducing low-value nursing care and, based on these results, to detect low-value practices probably existing in the hospital. BACKGROUND Low-value nursing care refers to clinical practices with poor or no benefit for patients that may be harmful and a waste of resources. Detecting these practices and understanding nurses' perceptions are essential to developing effective interventions to reduce them. METHODS We conducted a survey in a tertiary hospital. STROBE guidelines were followed. The questionnaire appraised nurses' agreement, subjective adherence and perception of usefulness of a group of recommendations to reduce low-value nursing care from Choosing Wisely and other initiatives. Practices described in recommendations with an agreement over 70% and a subjective adherence under 70% were categorised as low-value practices probably existing in the hospital. RESULTS A total of 265 nurses from eight areas of care participated in the survey. The response rate by area ranged between 2%-55%. From the 38 recommendations evaluated, agreement was 96% (95% confidence interval [95%CI], 95%-97%), median subjective adherence was 80% (95%CI, 80%-85%), and usefulness was 90% (95%CI, 89%-92%). Based on these results, we detected seven (0-15) low-value practices probably existing in our hospital, mostly on general practice, pregnancy care and wound care. CONCLUSIONS We found a great understanding of low-value care between nurses, given the high agreement to recommendations and perception of usefulness. However, several low-value practices may be present in nursing care, requiring actions to reduce them, for instance, reviewing institutional protocols and involving patients in de-implementation. RELEVANCE TO CLINICAL PRACTICE Hospitals and other settings should be aware of low-value practices and take actions to identify and reduce them. A survey may be a simple and helpful way to start this process.
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Affiliation(s)
- Dimelza Osorio
- Health Services Research Group-Vall d'Hebron Research Institute (VHIR), Barcelona, Spain.,Center for Biomedical Research in the Epidemiology and Public Health Network (CIBERESP), Barcelona, Spain
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