Drivers and strategies for avoiding overuse. A cross-sectional study to explore the experience of Spanish primary care providers handling uncertainty and patients’ requests

Abstract

ObjectivesIdentify the sources of overuse from the point of view of the Spanish primary care professionals, and analyse the frequency of overuse due to pressure from patients in addition to the responses when professionals face these demands.DesignA cross-sectional study.SettingPrimary care in Spain.ParticipantsA non-randomised sample of 2201 providers (general practitioners, paediatricians and nurses) was recruited during the survey.Primary and secondary outcome measuresThe frequency, causes and responsibility for overuse, the frequency that patients demand unnecessary tests or procedures, the profile of the most demanding patients, and arguments for dissuading the patient.ResultsIn all, 936 general practitioners, 682 paediatricians and 286 nurses replied (response rate 18.6%). Patient requests (67%) and defensive medicine (40%) were the most cited causes of overuse. Five hundred and twenty-two (27%) received requests from their patients almost every day for unnecessary tests or procedures, and 132 (7%) recognised granting the requests. The lack of time in consultation, and information about new medical advances and treatments that patients could find on printed and digital media, contributed to the professional’s inability to adequately counter this pressure by patients. Clinical safety (49.9%) and evidence (39.4%) were the arguments that dissuaded patients from their requests the most. Cost savings was not a convincing argument (6.8%), above all for paediatricians (4.3%). General practitioners resisted more pressure from their patients (x2=88.8, P<0.001, percentage difference (PD)=17.0), while nurses admitted to carrying out more unnecessary procedures (x2=175.7, P<0.001, PD=12.3).ConclusionSatisfying the patient and patient uncertainty about what should be done and defensive medicine practices explains some of the frequent causes of overuse. Safety arguments are useful to dissuade patients from their requests.

Why Not? Persuading Clinicians to Reduce Overuse

“…In so doing, they described many clinician-identified drivers of overuse, including insulation from costs, fears of "missing something," and patient demands. [36][37][38] Often, the "yes, but" phenomenon revealed participants' disbelief that overuse can cause nontrivial harms, which is consistent with research showing that clinicians often underestimate interventions' harms and overestimate benefits. 39 Our findings contrast with those of a recent survey evaluating physician attitudes toward financial penalties to deter use of low-value services.…”

Identifying and de-implementing low-value care in primary care: the GP’s perspective—a cross-sectional survey

“…14 15 A study in Spain among GPs, nurses and paediatricians identified also lack of time as a crucial barrier, next to insufficient patient information. 16 A Swiss survey showed that GPs saw the specific request of patients as the most important barrier; time constraints and fear for malpractice suits were hardly mentioned. 17 A Dutch study identified the demand-satisfying attitude and the available diagnostic facilities as the most prominent barriers for GPs to avoid low-value care practices.…”

Low-value care practice in headache: a Spanish mixed methods research study

“…The literature reflects the outcome of interventions based on communication of the benefit of following these recommendations, acting on professional attitudes, knowledge, and behavior, or on changes in patient demands [25,26]. For example, the results of the Choosing Wisely campaign are inconsistent; while significant reductions in some "Do not Do" practices have been achieved, there has been no change in the implementations of others by professionals [27,28].…”