Key Factors that Promote Low-Value Care: Views of Experts From the United States, Canada, and the Netherlands

Abstract

Background: Around the world, policies and interventions are used to encourage clinicians to reduce low-value care. In order to facilitate this, we need a better understanding of the factors that lead to low-value care. We aimed to identify the key factors affecting low-value care on a national level. In addition, we highlight differences and similarities in three countries. Methods: We performed 18 semi-structured interviews with experts on low-value care from three countries that are actively reducing low-value care: the United States, Canada, and the Netherlands. We interviewed 5 experts from Canada, 6 from the United States, and 7 from the Netherlands. Eight were organizational leaders or policy-makers, 6 as low-value care researchers or project leaders, and 4 were both. The transcribed interviews were analyzed using inductive thematic analysis. Results: The key factors that promote low-value care are the payment system, the pharmaceutical and medical device industry, fear of malpractice litigation, biased evidence and knowledge, medical education, and a ‘more is better’ culture. These factors are seen as the most important in the United States, Canada and the Netherlands, although there are several differences between these countries in their payment structure, and industry and malpractice policy. Conclusion: Policy-makers and researchers that aim to reduce low-value care have experienced that clinicians face a mix of interdependent factors regarding the healthcare system and culture that lead them to provide low-value care. Better awareness and understanding of these factors can help policy-makers to facilitate clinicians and medical centers to deliver high-value care.

National governance of de-implementation of low-value care: a qualitative study in Sweden

“…To reduce the use of LVC, it is important to understand the factors influencing LVC and to tailor governance strategies to target these factors [11]. A recent study explored key national-level factors that promoted LVC use across three countries (the Netherlands, the United States and Canada) [9]. Our findings of national-level activities used to govern the de-implementation of LVC in Sweden targeted two of these key factors: the pharmaceutical and medical device industry and biased knowledge of care.…”

“…Our findings of national-level activities used to govern the de-implementation of LVC in Sweden targeted two of these key factors: the pharmaceutical and medical device industry and biased knowledge of care. Verkerk et al [9] describe industry as a powerful actor contributing to LVC by advertising medical products to the population and through their influence on policy-makers and education and research funding. Our results showed that the control of pharmaceutical products, including the withdrawal of unsafe pharmaceutical products, removal of the substitution of medicines and controlling the pricing of products, was used for governing the de-implementation of LVC.…”

“…Thus, an important issue for researchers and policy-makers is in recognizing factors affecting LVC use and improving knowledge regarding the strategies that could be effective for reducing LVC. A recent study identified key factors on the national level influencing the use of LVC, which were found to be similar across three countries (United States, Canada, Netherlands) despite differences in their health systems [9]. The factors included the provider payment system, the pharmaceutical and medical device industry, fear of malpractice litigation, biased evidence and knowledge, medical education, and social factors around healthcare including medical and public culture.…”

Overview of the Drivers of Low-Value Care Comment on "Key Factors that Promote Low-Value Care: Views of Experts From the United States, Canada, and the Netherlands"

“…Money, Finance, and Organisation: Health Coverage, Resource Allocation and the Organisation of Care Delivery, Financing and Configuration of Health Systems, and Integration Across Levels of Care Money, finance, and organisation were major drivers of low-value care in the Lancet Right Care Series 4 but were only briefly touched on by the participants in Verkerk and colleagues study 1 . Inadequate health insurance coverage can prevent people from accessing essential care (eg, if people are uninsured or underinsured, or if a health insurer does not cover a specific service).…”

“…Power and Human Relationships: Strengths or Weaknesses of the Therapeutic Relationship, Flawed Decision-Making, Contest for Political Control, Political Mobilisation and Demand for Care, Professional Societies and Other Mediators, and Fear of Litigation Fear of litigation was discussed at length in the article by Verkerk and colleagues. 1 Yet, there are other factors related to power and human relationships that can exert their force on the provision of low-value care. The patient-clinician relationship at the point of care is ultimately where low-value care manifests.…”