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Lang G, Ingvarsson S, Hasson H, Nilsen P, Augustsson H. Organizational influences on the use of low-value care in primary health care - a qualitative interview study with physicians in Sweden. Scand J Prim Health Care 2022; 40:426-437. [PMID: 36325746 PMCID: PMC9848255 DOI: 10.1080/02813432.2022.2139467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
AIM The aim was (1) to explore organizational factors influencing the use of low-value care (LVC) as perceived by primary care physicians and (2) to explore which organizational strategies they believe are useful for reducing the use of LVC. DESIGN Qualitative study with semi-structured focus group discussions (FGDs) analyzed using qualitative content analysis. SETTING Six publicly owned primary health care centers in Stockholm. SUBJECTS The participants were 31 primary care physicians. The number of participants in each FGD varied between 3 and 7. MAIN OUTCOME MEASURES Categories and subcategories reporting organizational factors perceived to influence the use of LVC and organizational strategies considered useful for reducing the use of LVC. RESULTS Four types of organizational factors (resources, care processes, improvement activities, and governance) influenced the use of LVC. Resources involved time to care for patients, staff knowledge, and working tools. Care processes included work routines and the ways activities and resources were prioritized in the organization. Improvement activities involved performance measurement and improvement work to reduce LVC. Governance concerned organizational goals, higher-level decision making, and policies. Physicians suggested multiple strategies targeting these factors to reduce LVC, including increased patient-physician continuity, adjusted economic incentives, continuous professional development for physicians, and gatekeeping functions which prevent unnecessary appointments and guide patients to the appropriate point of care. . CONCLUSION The influence of multiple organizational factors throughout the health-care system indicates that a whole-system approach might be useful in reducing LVC.KEY POINTSWe know little about how organizational factors influence the use of low-value care (LVC) in primary health care.Physicians perceive organizational resources, care processes, improvement activities, and governance as influences on the use of LVC and LVC-reducing strategies.This study provides insights about how these factors influence LVC use.Strategies at multiple levels of the health-care system may be warranted to reduce LVC.
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Affiliation(s)
- Gabriella Lang
- Procome Research Group, Department of Learning, Informatics, Management and Ethics, Medical Management Centre, Karolinska Institutet, Stockholm, Sweden
- CONTACT Gabriella Lang Procome Research Group, Department of Learning, Informatics, Management and Ethics, Medical Management Centre, Karolinska Institutet, Stockholm, SE 171 77, Sweden
| | - Sara Ingvarsson
- Procome Research Group, Department of Learning, Informatics, Management and Ethics, Medical Management Centre, Karolinska Institutet, Stockholm, Sweden
| | - Henna Hasson
- Procome Research Group, Department of Learning, Informatics, Management and Ethics, Medical Management Centre, Karolinska Institutet, Stockholm, Sweden
- Unit for Implementation and Evaluation, Center for Epidemiology and Community Medicine (CES), Region Stockholm, Stockholm, Sweden
| | - Per Nilsen
- Division of Society and Health, Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Hanna Augustsson
- Procome Research Group, Department of Learning, Informatics, Management and Ethics, Medical Management Centre, Karolinska Institutet, Stockholm, Sweden
- Unit for Implementation and Evaluation, Center for Epidemiology and Community Medicine (CES), Region Stockholm, Stockholm, Sweden
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Kroon D, van Dulmen SA, Westert GP, Jeurissen PPT, Kool RB. Development of the SPREAD framework to support the scaling of de-implementation strategies: a mixed-methods study. BMJ Open 2022; 12:e062902. [PMID: 36343997 PMCID: PMC9644331 DOI: 10.1136/bmjopen-2022-062902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
OBJECTIVE We aimed to increase the understanding of the scaling of de-implementation strategies by identifying the determinants of the process and developing a determinant framework. DESIGN AND METHODS This study has a mixed-methods design. First, we performed an integrative review to build a literature-based framework describing the determinants of the scaling of healthcare innovations and interventions. PubMed and EMBASE were searched for relevant studies from 1995 to December 2020. We systematically extracted the determinants of the scaling of interventions and developed a literature-based framework. Subsequently, this framework was discussed in four focus groups with national and international de-implementation experts. The literature-based framework was complemented by the findings of the focus group meetings and adapted for the scaling of de-implementation strategies. RESULTS The literature search resulted in 42 articles that discussed the determinants of the scaling of innovations and interventions. No articles described determinants specifically for de-implementation strategies. During the focus groups, all participants agreed on the relevance of the extracted determinants for the scaling of de-implementation strategies. The experts emphasised that while the determinants are relevant for various countries, the implications differ due to different contexts, cultures and histories. The analyses of the focus groups resulted in additional topics and determinants, namely, medical training, professional networks, interests of stakeholders, clinical guidelines and patients' perspectives. The results of the focus group meetings were combined with the literature framework, which together formed the supporting the scaling of de-implementation strategies (SPREAD) framework. The SPREAD framework includes determinants from four domains: (1) scaling plan, (2) external context, (3) de-implementation strategy and (4) adopters. CONCLUSIONS The SPREAD framework describes the determinants of the scaling of de-implementation strategies. These determinants are potential targets for various parties to facilitate the scaling of de-implementation strategies. Future research should validate these determinants of the scaling of de-implementation strategies.
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Affiliation(s)
| | | | | | | | - Rudolf B Kool
- IQ Healthcare, Radboudumc, Nijmegen, The Netherlands
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3
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Ingvarsson S, Hasson H, von Thiele Schwarz U, Nilsen P, Powell BJ, Lindberg C, Augustsson H. Strategies for de-implementation of low-value care-a scoping review. Implement Sci 2022; 17:73. [PMID: 36303219 PMCID: PMC9615304 DOI: 10.1186/s13012-022-01247-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 10/13/2022] [Indexed: 11/27/2022] Open
Abstract
Background The use of low-value care (LVC) is a persistent problem that calls for knowledge about strategies for de-implementation. However, studies are dispersed across many clinical fields, and there is no overview of strategies that can be used to support the de-implementation of LVC. The extent to which strategies used for implementation are also used in de-implementing LVC is unknown. The aim of this scoping review is to (1) identify strategies for the de-implementation of LVC described in the scientific literature and (2) compare de-implementation strategies to implementation strategies as specified in the Expert Recommendation for Implementing Change (ERIC) and strategies added by Perry et al. Method A scoping review was conducted according to recommendations outlined by Arksey and O’Malley. Four scientific databases were searched, relevant articles were snowball searched, and the journal Implementation Science was searched manually for peer-reviewed journal articles in English. Articles were included if they were empirical studies of strategies designed to reduce the use of LVC. Two reviewers conducted all abstract and full-text reviews, and conflicting decisions were discussed until consensus was reached. Data were charted using a piloted data-charting form. The strategies were first coded inductively and then mapped onto the ERIC compilation of implementation strategies. Results The scoping review identified a total of 71 unique de-implementation strategies described in the literature. Of these, 62 strategies could be mapped onto ERIC strategies, and four strategies onto one added category. Half (50%) of the 73 ERIC implementation strategies were used for de-implementation purposes. Five identified de-implementation strategies could not be mapped onto any of the existing strategies in ERIC. Conclusions Similar strategies are used for de-implementation and implementation. However, only a half of the implementation strategies included in the ERIC compilation were represented in the de-implementation studies, which may imply that some strategies are being underused or that they are not applicable for de-implementation purposes. The strategies assess and redesign workflow (a strategy previously suggested to be added to ERIC), accountability tool, and communication tool (unique new strategies for de-implementation) could complement the existing ERIC compilation when used for de-implementation purposes. Supplementary Information The online version contains supplementary material available at 10.1186/s13012-022-01247-y.
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Affiliation(s)
- Sara Ingvarsson
- Procome Research Group, Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Karolinska, Sweden.
| | - Henna Hasson
- Procome Research Group, Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Karolinska, Sweden.,Unit for implementation and evaluation, Center for Epidemiology and Community Medicine (CES), Stockholm Region, Stockholm, Sweden
| | - Ulrica von Thiele Schwarz
- Procome Research Group, Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Karolinska, Sweden.,School of Health, Care and Social Welfare, Mälardalen University, Västerås, Sweden
| | - Per Nilsen
- Department of Health, Medicine and Caring Sciences, Division of Public Health, Linköping University, Linköping, Sweden
| | - Byron J Powell
- Center for Mental Health Services Research, Brown School, Washington University in St. Louis, St. Louis, MO, USA.,Center for Dissemination and Implementation, Institute for Public Health, Washington University in St. Louis, St. Louis, MO, USA.,Division of Infectious Diseases, John T. Milliken Department of Medicine, School of Medicine, Washington University in St. Louis, St. Louis, MO, USA
| | - Clara Lindberg
- Procome Research Group, Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Karolinska, Sweden
| | - Hanna Augustsson
- Procome Research Group, Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Karolinska, Sweden.,Unit for implementation and evaluation, Center for Epidemiology and Community Medicine (CES), Stockholm Region, Stockholm, Sweden
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4
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Ries NM, Johnston B, Jansen J. A qualitative interview study of Australian physicians on defensive practice and low value care: "it's easier to talk about our fear of lawyers than to talk about our fear of looking bad in front of each other". BMC Med Ethics 2022; 23:16. [PMID: 35246129 PMCID: PMC8895622 DOI: 10.1186/s12910-022-00755-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 02/18/2022] [Indexed: 12/27/2022] Open
Abstract
Background Defensive practice occurs when physicians provide services, such as tests, treatments and referrals, mainly to reduce their perceived legal or reputational risks, rather than to advance patient care. This behaviour is counter to physicians’ ethical responsibilities, yet is widely reported in surveys of doctors in various countries. There is a lack of qualitative research on the drivers of defensive practice, which is needed to inform strategies to prevent this ethically problematic behaviour. Methods A qualitative interview study investigated the views and experiences of physicians in Australia on defensive practice and its contribution to low value care. Interviewees were recruited based on interest in medico-legal issues or experience in a health service involved in ‘Choosing Wisely’ initiatives. Semi-structured interviews averaged 60 min in length. Data were coded using the Theoretical Domains Framework, which encapsulates theories of behaviour and behaviour change. Results All participants (n = 17) perceived defensive practice as a problem and a contributor to low value care. Behavioural drivers of defensive practice spanned seven domains in the TDF: knowledge, focused on inadequate knowledge of the law and the risks of low value care; skills, emphasising patient communication and clinical decision-making skills; professional role and identity, particularly clinicians’ perception of patient expectations and concern for their professional reputation; beliefs about consequences, especially perceptions of the beneficial and harmful consequences of defensive practice; environmental context and resources, including processes for handling patient complaints; social influences, focused on group norms that encourage or discourage defensive behaviour; and emotions, especially fear of missing a diagnosis. Overall, defensive practice is motivated by physicians’ desire to avoid criticism or scrutiny from a range of sources, and censure from their professional peers can be a more potent driver than perceived legal consequences. Conclusions The findings call for strengthening knowledge and skills, for example, to improve clinicians’ understanding of the law and their awareness of the risks of low value care and using effective communication strategies with patients. Importantly, supportive cultures of practice and organisational environments are needed to create conditions in which clinicians feel confident in avoiding defensive practice and other forms of low value care. Supplementary Information The online version contains supplementary material available at 10.1186/s12910-022-00755-2.
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Affiliation(s)
- Nola M Ries
- Faculty of Law, University of Technology Sydney, PO Box 123, Sydney, NSW, 2007, Australia.
| | - Briony Johnston
- Faculty of Law, University of Technology Sydney, PO Box 123, Sydney, NSW, 2007, Australia
| | - Jesse Jansen
- School for Public Health and Primary Care, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
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Hahn EE, Munoz-Plaza C, Altman DE, Hsu C, Cannizzaro NT, Ngo-Metzger Q, Wride P, Gould MK, Mittman BS, Hodeib M, Tewari KS, Ajamian LH, Eskander RN, Tewari D, Chao CR. De-implementation and substitution of clinical care processes: stakeholder perspectives on the transition to primary human papillomavirus (HPV) testing for cervical cancer screening. Implement Sci Commun 2021; 2:108. [PMID: 34556189 PMCID: PMC8461958 DOI: 10.1186/s43058-021-00211-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 09/06/2021] [Indexed: 12/27/2022] Open
Abstract
Background New cervical cancer screening guidelines recommend primary human papillomavirus (HPV) testing for women age 30–65 years. Healthcare organizations are preparing to de-implement the previous recommended strategies of Pap testing or co-testing (Pap plus HPV test) and substitute primary HPV testing. However, there may be significant challenges to the replacement of this entrenched clinical practice, even with an evidence-based substitution. We sought to identify stakeholder-perceived barriers and facilitators to this substitution within a large healthcare system, Kaiser Permanente Southern California. Methods We conducted semi-structured qualitative interviews with clinician, administrative, and patient stakeholders regarding (a) acceptability and feasibility of the planned substitution; (b) perceptions of barriers and facilitators, with an emphasis on those related to the de-implementation/implementation cycle of substitution; and (c) perceived readiness to change. Our interview guide was informed by the Consolidated Framework for Implementation Research (CFIR). Using a team coding approach, we developed an initial coding structure refined during iterative analysis; the data were subsequently organized thematically into domains, key themes, and sub-themes using thematic analysis, followed by framework analysis informed by CFIR. Results We conducted 23 interviews: 5 patient and 18 clinical/administrative. Clinicians perceived that patients feel more tests equals better care, and clinicians and patients expressed fear of missed cancers (“…it’ll be more challenging convincing the patient that only one test is…good enough to detect cancer.”). Patients perceived practice changes resulting in “less care” are driven by the desire to cut costs. In contrast, clinicians/administrators viewed changing from two tests to one as acceptable and a workflow efficiency (“…It’s very easy and half the work.”). Stakeholder-recommended strategies included focusing on the increased efficacy of primary HPV testing and developing clinician talking points incorporating national guidelines to assuage “cost-cutting” fears. Conclusions Substitution to replace an entrenched clinical practice is complex. Leveraging available facilitators is key to ease the process for clinical and administrative stakeholders—e.g., emphasizing the efficiency of going from two tests to one. Identifying and addressing clinician and patient fears regarding cost-cutting and perceived poorer quality of care is critical for substitution. Multicomponent and multilevel strategies for engagement and education will be required. Trial registration ClinicalTrials.gov, #NCT04371887 Supplementary Information The online version contains supplementary material available at 10.1186/s43058-021-00211-z.
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Affiliation(s)
- Erin E Hahn
- Department of Research and Evaluation, Kaiser Permanente Southern California, 100 S. Los Robles Ave, Pasadena, CA, 91101, USA. .,Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA, USA.
| | - Corrine Munoz-Plaza
- Department of Research and Evaluation, Kaiser Permanente Southern California, 100 S. Los Robles Ave, Pasadena, CA, 91101, USA
| | - Danielle E Altman
- Center for Health Living, Kaiser Permanente Southern California, Pasadena, USA
| | - Chunyi Hsu
- Department of Research and Evaluation, Kaiser Permanente Southern California, 100 S. Los Robles Ave, Pasadena, CA, 91101, USA
| | - Nancy T Cannizzaro
- Department of Research and Evaluation, Kaiser Permanente Southern California, 100 S. Los Robles Ave, Pasadena, CA, 91101, USA
| | - Quyen Ngo-Metzger
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA, USA
| | - Patricia Wride
- Southern California Permanente Medical Group, Pasadena, USA
| | - Michael K Gould
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA, USA
| | - Brian S Mittman
- Department of Research and Evaluation, Kaiser Permanente Southern California, 100 S. Los Robles Ave, Pasadena, CA, 91101, USA
| | - Melissa Hodeib
- Southern California Permanente Medical Group, Pasadena, USA
| | - Krishnansu S Tewari
- Department of Gynecologic Oncology, University of California Irvine, Irvine, CA, USA
| | - Lena H Ajamian
- Southern California Permanente Medical Group, Pasadena, USA
| | - Ramez N Eskander
- Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Diego, La Jolla, CA, USA
| | - Devansu Tewari
- Southern California Permanente Medical Group, Pasadena, USA
| | - Chun R Chao
- Department of Research and Evaluation, Kaiser Permanente Southern California, 100 S. Los Robles Ave, Pasadena, CA, 91101, USA.,Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA, USA
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6
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Physicians' views and experiences of defensive medicine: An international review of empirical research. Health Policy 2021; 125:634-642. [PMID: 33676778 DOI: 10.1016/j.healthpol.2021.02.005] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 02/03/2021] [Accepted: 02/23/2021] [Indexed: 12/22/2022]
Abstract
This study systematically maps empirical research on physicians' views and experiences of hedging-type defensive medicine, which involves providing services (eg, tests, referrals) to reduce perceived legal risks. Such practices drive over-treatment and low value healthcare. Data sources were empirical, English-language publications in health, legal and multi-disciplinary databases. The extraction framework covered: where and when the research was conducted; what methods of data collection were used; who the study participants were; and what were the study aims, main findings in relation to hedging-type defensive practices, and proposed solutions. 79 papers met inclusion criteria. Defensive medicine has mainly been studied in the United States and European countries using quantitative surveys. Surgery and obstetrics have been key fields of investigation. Hedging-type practices were commonly reported, including: ordering unnecessary tests, treatments and referrals; suggesting invasive procedures against professional judgment; ordering hospitalisation or delaying discharge; and excessive documentation in medical records. Defensive practice was often framed around the threat of negligence lawsuits, but studies recognised other legal risks, including patient complaints and regulatory investigations. Potential solutions to defensive medicine were identified at macro (law, policy), meso (organisation, profession) and micro (physician) levels. Areas for future research include qualitative studies to investigate the behavioural drivers of defensive medicine and intervention research to determine policies and practices that work to support clinicians in de-implementing defensive, low-value care.
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Augustsson H, Ingvarsson S, Nilsen P, von Thiele Schwarz U, Muli I, Dervish J, Hasson H. Determinants for the use and de-implementation of low-value care in health care: a scoping review. Implement Sci Commun 2021; 2:13. [PMID: 33541443 PMCID: PMC7860215 DOI: 10.1186/s43058-021-00110-3] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 01/14/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND A considerable proportion of interventions provided to patients lack evidence of their effectiveness. This implies that patients may receive ineffective, unnecessary or even harmful care. However, despite some empirical studies in the field, there has been no synthesis of determinants impacting the use of low-value care (LVC) and the process of de-implementing LVC. AIM The aim was to identify determinants influencing the use of LVC, as well as determinants for de-implementation of LVC practices in health care. METHODS A scoping review was performed based on the framework by Arksey and O'Malley. We searched four scientific databases, conducted snowball searches of relevant articles and hand searched the journal Implementation Science for peer-reviewed journal articles in English. Articles were included if they were empirical studies reporting on determinants for the use of LVC or de-implementation of LVC. The abstract review and the full-text review were conducted in duplicate and conflicting decisions were discussed until consensus was reached. Data were charted using a piloted data charting form and the determinants were inductively coded and categorised in an iterative process conducted by the project group. RESULTS In total, 101 citations were included in the review. Of these, 92 reported on determinants for the use of LVC and nine on determinants for de-implementation. The studies were conducted in a range of health care settings and investigated a variety of LVC practices with LVC medication prescriptions, imaging and screening procedures being the most common. The identified determinants for the use of LVC as well as for de-implementation of LVC practices broadly concerned: patients, professionals, outer context, inner context, process and evidence and LVC practice. The results were discussed in relation to the Consolidated Framework for Implementation Research. CONCLUSION The identified determinants largely overlap with existing implementation frameworks, although patient expectations and professionals' fear of malpractice appear to be more prominent determinants for the use and de-implementation of LVC. Thus, existing implementation determinant frameworks may require adaptation to be transferable to de-implementation. Strategies to reduce the use of LVC should specifically consider determinants for the use and de-implementation of LVC. REGISTRATION The review has not been registered.
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Affiliation(s)
- Hanna Augustsson
- Procome Research Group, Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, SE 171 77 Stockholm, Sweden
- Unit for Implementation and Evaluation, Center for Epidemiology and Community Medicine (CES), Stockholm Region, SE 171 29 Stockholm, Sweden
| | - Sara Ingvarsson
- Procome Research Group, Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, SE 171 77 Stockholm, Sweden
| | - Per Nilsen
- Department of Health, Medical and Caring Sciences, Division of Society and Health, Linköping University, Linköping, Sweden
| | - Ulrica von Thiele Schwarz
- Procome Research Group, Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, SE 171 77 Stockholm, Sweden
- School of Health, Care and Social Welfare, Mälardalen University, Box 883, 721 23 Västerås, Sweden
| | - Irene Muli
- Unit for Implementation and Evaluation, Center for Epidemiology and Community Medicine (CES), Stockholm Region, SE 171 29 Stockholm, Sweden
| | - Jessica Dervish
- Unit for Implementation and Evaluation, Center for Epidemiology and Community Medicine (CES), Stockholm Region, SE 171 29 Stockholm, Sweden
| | - Henna Hasson
- Procome Research Group, Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, SE 171 77 Stockholm, Sweden
- Unit for Implementation and Evaluation, Center for Epidemiology and Community Medicine (CES), Stockholm Region, SE 171 29 Stockholm, Sweden
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Burton CR, Williams L, Bucknall T, Fisher D, Hall B, Harris G, Jones P, Makin M, Mcbride A, Meacock R, Parkinson J, Rycroft-Malone J, Waring J. Theory and practical guidance for effective de-implementation of practices across health and care services: a realist synthesis. HEALTH SERVICES AND DELIVERY RESEARCH 2021. [DOI: 10.3310/hsdr09020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Background
Health-care systems across the globe are facing increased pressures to balance the efficient use of resources and at the same time provide high-quality care. There is greater requirement for services to be evidence based, but practices that are of limited clinical effectiveness or cost-effectiveness still occur.
Objectives
Our objectives included completing a concept analysis of de-implementation, surfacing decision-making processes associated with de-implementing through stakeholder engagement, and generating an evidence-based realist programme theory of ‘what works’ in de-implementation.
Design
A realist synthesis was conducted using an iterative stakeholder-driven four-stage approach. Phase 1 involved scoping the literature and conducting stakeholder interviews to develop the concept analysis and an initial programme theory. In Phase 2, systematic searches of the evidence were conducted to test and develop this theory, expressed in the form of contingent relationships. These are expressed as context–mechanism–outcomes to show how particular contexts or conditions trigger mechanisms to generate outcomes. Phase 3 consisted of validation and refinement of programme theories through stakeholder interviews. The final phase (i.e. Phase 4) formulated actionable recommendations for service leaders.
Participants
In total, 31 stakeholders (i.e. user/patient representatives, clinical managers, commissioners) took part in focus groups and telephone interviews.
Data sources
Using keywords identified during the scoping work and concept analysis, searches of bibliographic databases were conducted in May 2018. The databases searched were the Cochrane Library, Campbell Collaboration, MEDLINE (via EBSCOhost), the Cumulative Index to Nursing and Allied Health Literature (via EBSCOhost), the National Institute for Health Research Journals Library and the following databases via the ProQuest platform: Applied Social Sciences Index and Abstracts, Social Services Abstracts, International Bibliography of the Social Sciences, Social Sciences Database and Sociological Abstracts. Alerts were set up for the MEDLINE database from May 2018 to December 2018. Online sources were searched for grey literature and snowballing techniques were used to identify clusters of evidence.
Results
The concept analysis showed that de-implementation is associated with five main components in context and over time: (1) what is being de-implemented, (2) the issues driving de-implementation, (3) the action characterising de-implementation, (4) the extent that de-implementation is planned or opportunistic and (5) the consequences of de-implementation. Forty-two papers were synthesised to identify six context–mechanism–outcome configurations, which focused on issues ranging from individual behaviours to organisational procedures. Current systems can perpetuate habitual decision-making practices that include low-value treatments. Electronic health records can be designed to hide or remove low-value treatments from choice options, foregrounding best evidence. Professionals can be made aware of their decision-making strategies through increasing their attention to low-value practice behaviours. Uncertainty about diagnosis or patients’ expectations for certain treatments provide opportunities for ‘watchful waiting’ as an active strategy to reduce inappropriate investigations and prescribing. The emotional component of clinician–patient relationships can limit opportunities for de-implementation, requiring professional support through multimodal educational interventions. Sufficient alignment between policy, public and professional perspectives is required for de-implementation success.
Limitations
Some specific clinical issues (e.g. de-prescribing) dominate the de-implementation evidence base, which may limit the transferability of the synthesis findings. Any realist inquiry generates findings that are essentially cumulative and should be developed through further investigation that extends the range of sources into, for example, clinical research and further empirical studies.
Conclusions
This review contributes to our understanding of how de-implementation of low-value procedures and services can be improved within health-care services, through interventions that make professional decision-making more accountable and the prominence of a whole-system approach to de-implementation. Given the whole-system context of de-implementation, a range of different dissemination strategies will be required to engage with different stakeholders, in different ways, to change practice and policy in a timely manner.
Study registration
This study is registered as PROSPERO CRD42017081030.
Funding
This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 2. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Christopher R Burton
- School of Allied and Public Health Professions, Canterbury Christ Church University, Canterbury, UK
| | - Lynne Williams
- School of Health Sciences, College of Health and Behavioural Sciences, Bangor University, Bangor, UK
| | - Tracey Bucknall
- School of Nursing and Midwifery, Deakin University, Melbourne, VIC, Australia
| | - Denise Fisher
- School of Health Sciences, College of Health and Behavioural Sciences, Bangor University, Bangor, UK
| | - Beth Hall
- Library and Archives Services, Bangor University, Bangor, UK
| | - Gill Harris
- Betsi Cadwaladr University Health Board, Bangor, UK
| | - Peter Jones
- School of Health Sciences, College of Health and Behavioural Sciences, Bangor University, Bangor, UK
| | - Matthew Makin
- North Manchester Care Organisation, Pennine Acute Hospitals NHS Trust, Manchester, UK
| | - Anne Mcbride
- Alliance Manchester Business School, The University of Manchester, Manchester, UK
| | - Rachel Meacock
- Division of Population Health, Health Services Research and Primary Care, The University of Manchester, Manchester, UK
| | - John Parkinson
- School of Psychology, College of Human Sciences, Bangor University, Bangor, UK
| | | | - Justin Waring
- School of Social Policy, University of Birmingham, Birmingham, UK
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9
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Stefan MS, Spitzer KA, Zulfiqar S, Heineman BD, Hogan TP, Westafer LM, Pulia MS, Pinto-Plata VM, Lindenauer PK. Uncertainty as a critical determinant of antibiotic prescribing in patients with an asthma exacerbation: a qualitative study. J Asthma 2020; 59:352-361. [PMID: 33158364 DOI: 10.1080/02770903.2020.1847929] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To identify factors that influence providers' decisions to prescribe antibiotics in patients presenting to the hospital with an asthma exacerbation. METHODS We performed semi-structured interviews with a purposive sample of providers including sixteen hospitalists, emergency room providers, or pulmonologists, and one focus group with internal medicine residents recruited from one large, urban, teaching hospital and one small, rural, community hospital. Questions were informed by the Theoretical Domains Framework to determine factors that may influence behaviors. Directed content analysis was used to code and analyze transcripts of the interviews. RESULTS Uncertainty regarding the diagnostic (asthma vs. COPD) and the cause of exacerbation (bacterial vs. viral infection) emerged as the main driver for prescribing behavior. Provider response to uncertainty included: "watchful waiting" or immediate antibiotic prescribing. The following factors played important roles in providers' prescribing decision: 1) awareness/agreement with existing guidelines 2) confidence in their ability to apply the guidelines in challenging cases; 3) perceived risk of patient deterioration without antibiotics; 4) fear of litigation; 5) habit and clinical inertia 6) prescribing within the group 7) lack of information of antibiotic prescribing rates and 8) lack of time and/or resources. CONCLUSIONS We identified diagnostic uncertainty as the primary determinant of antibiotic prescribing in asthma exacerbations and developed a conceptual model to explain provider responses and factors that influenced their responses. These results enhance our understanding of the factors that can contribute to low-value and wasteful practices like superfluous antibiotic prescribing and will support the development of interventions to de-implement such practices.
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Affiliation(s)
- Mihaela S Stefan
- Institute for Healthcare Delivery and Population Science, University of Massachusetts Medical School - Baystate, Springfield, MA, USA.,Department of Medicine, University of Massachusetts Medical School - Baystate, Springfield, MA, USA
| | - Kerry A Spitzer
- Institute for Healthcare Delivery and Population Science, University of Massachusetts Medical School - Baystate, Springfield, MA, USA
| | - Sehar Zulfiqar
- Department of Medicine, University of Massachusetts Medical School - Baystate, Springfield, MA, USA
| | - Brent D Heineman
- Institute for Healthcare Delivery and Population Science, University of Massachusetts Medical School - Baystate, Springfield, MA, USA
| | - Timothy P Hogan
- Center for Healthcare Organization and Implementation Research (CHOIR), Edith Nourse Rogers Memorial Veterans Hospital, US Department of Veterans Affairs, Bedford, MA, USA.,Department of Population and Data Sciences, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Lauren M Westafer
- Institute for Healthcare Delivery and Population Science, University of Massachusetts Medical School - Baystate, Springfield, MA, USA.,Department of Emergency Medicine, University of Massachusetts Medical School - Baystate, Springfield, MA, USA
| | - Michael S Pulia
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin Madison, School of Medicine and Public Health, Madison, WI, USA
| | - Victor M Pinto-Plata
- Department of Medicine, University of Massachusetts Medical School - Baystate, Springfield, MA, USA.,Divsion of Pulmonary and Critical Care Medicine, University of Massachusetts Medical School - Baystate, Springfield, MA, USA
| | - Peter K Lindenauer
- Institute for Healthcare Delivery and Population Science, University of Massachusetts Medical School - Baystate, Springfield, MA, USA.,Department of Medicine, University of Massachusetts Medical School - Baystate, Springfield, MA, USA.,Department of Quantitative and Population Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
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10
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Chimonas SC, Diaz-MacInnis KL, Lipitz-Snyderman AN, Barrow BE, Korenstein DR. Why Not? Persuading Clinicians to Reduce Overuse. Mayo Clin Proc Innov Qual Outcomes 2020; 4:266-275. [PMID: 32542218 PMCID: PMC7283946 DOI: 10.1016/j.mayocpiqo.2020.01.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/16/2023] Open
Abstract
OBJECTIVE To explore how best to deimplement nonrecommended medical services, which can result in excess costs and patient harm. METHODS We conducted telephone interviews with 15 providers at 3 health systems from June 19 to November 21, 2017. Using the case of nonrecommended imaging in patients with cancer, participants assessed the potential for 7 rationales or "arguments," each characterizing overuse in terms of a single problem type (cost or quality) and affected stakeholder group (clinicians, institutions, society, or patients), to convince colleagues to change their practices. We tested rationales for all problem-stakeholder combinations appearing in prior deimplementation studies. RESULTS Participants' views varied widely. Relatively few found cost arguments powerful, except for patients' out-of-pocket costs. Participants were divided on institution-quality and clinician-quality rationales. Patient-quality rationales resonated strongly with nearly all participants. However, a "yes, but" phenomenon emerged: after initially expressing strong support for a rationale, participants often undercut it with denials or rationalizations. CONCLUSION Deimplementation efforts should combine multiple rationales appealing to clinicians' diverse perspectives and priorities. In addition, efforts must consider the complex cognitive dynamics that can undercut data and reasoned argumentation.
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Affiliation(s)
- Susan C. Chimonas
- Center for Health Policy and Outcomes, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | | | - Allison N. Lipitz-Snyderman
- Center for Health Policy and Outcomes, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Brooke E. Barrow
- Center for Health Policy and Outcomes, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Deborah R. Korenstein
- Center for Health Policy and Outcomes, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Medicine, Weill Cornell Medicine, New York, NY
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11
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Sanchez A, Pijoan JI, Pablo S, Mediavilla M, de Rozas RS, Lekue I, Gonzalez-Larragan S, Lantaron G, Argote J, García-Álvarez A, Latorre PM, Helfrich CD, Grandes G. Addressing low-value pharmacological prescribing in primary prevention of CVD through a structured evidence-based and theory-informed process for the design and testing of de-implementation strategies: the DE-imFAR study. Implement Sci 2020; 15:8. [PMID: 31969175 PMCID: PMC6977270 DOI: 10.1186/s13012-020-0966-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Accepted: 01/06/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND De-implementation or abandonment of ineffective or low-value healthcare is becoming a priority research field globally due to the growing empirical evidence of the high prevalence of such care and its impact in terms of patient safety and social inefficiency. Little is known, however, about the factors, barriers, and facilitators involved or about interventions that are effective in promoting and accelerating the de-implementation of low-value healthcare. The De-imFAR study seeks to carry out a structured, evidence-based, and theory-informed process involving the main stakeholders (clinicians, managers, patients, and researchers) for the design, deployment, and assessment of de-implementation strategies for reducing low-value pharmacological prescribing. METHODS A phase I formative study using a systematic and comprehensive framework based on theory and evidence for the design of implementation strategies-specifically, the Behavior Change Wheel (BCW)-will be conducted to design and model de-implementation strategies to favor reductions in low-value pharmacological prescribing of statins in primary prevention of cardiovascular disease (CVD) by main stakeholders (clinicians, managers, patients, and researchers) in a collegiate way. Subsequently, a phase II comparative hybrid trial will be conducted to assess the feasibility and potential effectiveness of at least one active de-implementation strategy to reduce low-value pharmacological prescribing of statins in primary prevention of CVD compared to the usual procedures for dissemination of clinical practice guidelines ("what-not-to-do" recommendations). A mixed-methods evaluation will be used: quantitative for the results of the implementation at the professional level (e.g., adoption, reach and implementation or execution of the recommended clinical practice); and qualitative to determine the feasibility and perceived impact of the de-implementation strategies from the clinicians' perspective, and patients' experiences related to the clinical care received. DISCUSSION The DE-imFAR study aims to generate valid scientific knowledge about the design and development of de-implementation strategies using theory- and evidence-based methodologies suggested by implementation science. It will explore the effectiveness of these strategies and their acceptability among clinicians, policymakers, and patients. Its ultimate goal is to maximize the quality and efficiency of our health system by abandoning low-value pharmacological prescribing. TRIAL REGISTRATION Clinicaltrials.gov identifier: NCT04022850. Registered 17 July 2019.
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Affiliation(s)
- Alvaro Sanchez
- Primary Care Research Unit, BioCruces Bizkaia Health Research Institute, Basque Healthcare Service, Osakidetza, Plaza Cruces s/n, E-48903 Barakaldo, Spain
| | - Jose Ignacio Pijoan
- Clinical Epidemiology Unit, Hospital Universitario de Cruces. BioCruces Bizkaia Health Research Institute, Basque Healthcare Service-Osakidetza, Plaza Cruces s/n, E-48903 Barakaldo, Spain
| | - Susana Pablo
- Primary Care Research Unit, BioCruces Bizkaia Health Research Institute, Basque Healthcare Service, Osakidetza, Plaza Cruces s/n, E-48903 Barakaldo, Spain
| | - Marta Mediavilla
- Primary Care Research Unit, BioCruces Bizkaia Health Research Institute, Basque Healthcare Service, Osakidetza, Plaza Cruces s/n, E-48903 Barakaldo, Spain
| | - Rita Sainz de Rozas
- Primary Care Pharmacy Unit, Ezkerraldea-Enkarterri-Cruces Integrated Health Organization – Osakidetza, Plaza Cruces s/n, E-48903 Barakaldo, Spain
| | - Itxasne Lekue
- Primary Care Pharmacy Unit, Barakaldo-Sestao Integrated Health Organization–Osakidetza, Antonio Miranda Etorbidea, E-48902 Barakaldo, Spain
| | - Susana Gonzalez-Larragan
- Department of Health Science Library, Cruces University Hospital-Osakidetza, Biocruces Bizkaia Health Research Institute, Plaza Cruces s/n, E-48903 Barakaldo, Spain
| | - Gaspar Lantaron
- Healthcare Integration Directorate, Ezkerraldea-Enkarterri-Cruces Integrated Health Organization–Osakidetza, Plaza Cruces s/n, E-48903 Barakaldo, Spain
| | - Jon Argote
- Healthcare Integration Directorate, Barakaldo-Sestao Integrated Health Organization–Osakidetza, Antonio Miranda Etorbidea, E-48902 Barakaldo, Spain
| | - Arturo García-Álvarez
- Primary Care Research Unit, BioCruces Bizkaia Health Research Institute, Basque Healthcare Service, Osakidetza, Plaza Cruces s/n, E-48903 Barakaldo, Spain
| | - Pedro Maria Latorre
- Primary Care Research Unit, BioCruces Bizkaia Health Research Institute, Basque Healthcare Service, Osakidetza, Plaza Cruces s/n, E-48903 Barakaldo, Spain
| | - Christian D. Helfrich
- Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care VA Puget Sound Health Care System, Seattle, USA
- Department of Health Services, University of Washington School of Public Health, Seattle, USA
| | - Gonzalo Grandes
- Primary Care Research Unit, BioCruces Bizkaia Health Research Institute, Basque Healthcare Service, Osakidetza, Plaza Cruces s/n, E-48903 Barakaldo, Spain
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Takahashi Y, Hikiji H, Nishihara T. A preliminary study of the scope of practice of dental hygienists and oral health providers in Asia. J Oral Sci 2020; 62:449-451. [DOI: 10.2334/josnusd.20-0087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Affiliation(s)
- Yukiko Takahashi
- Department of Oral Health Kobe Tokiwa Junior College
- School of Oral Health Sciences, Kyushu Dental University
| | - Hisako Hikiji
- School of Oral Health Sciences, Kyushu Dental University
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