Strategies to reduce low-value care – An applied behavior analysis using a single-case design

Abstract

IntroductionImplementation science has traditionally focused on the implementation of evidence-based practices, but the field has increasingly recognized the importance of addressing de-implementation (i.e., the process of reducing low-value care). Most studies on de-implementation strategies have used a combination of strategies without addressing factors that sustain the use of LVC and there is a lack of information about which strategies are most effective and what mechanisms of change might underlie these strategies. Applied behavior analysis is an approach that could be a potential method to gain insights into the mechanisms of de-implementation strategies to reduce LVC. Three research questions are addressed in this study: What contingencies (three-term contingencies or rule-governing behavior) related to the use of LVC can be found in a local context and what strategies can be developed based on an analysis of these contingencies?; Do these strategies change targeted behaviors?; How do the participants describe the strategies' contingencies and the feasibility of the applied behavior analysis approach?Materials and methodsIn this study, we used applied behavior analysis to analyze contingencies that maintain behaviors related to a chosen LVC, the unnecessary use of x-rays for knee arthrosis within a primary care center. Based on this analysis, strategies were developed and evaluated using a single-case design and a qualitative analysis of interview data.ResultsTwo strategies were developed: a lecture and feedback meetings. The results from the single-case data were inconclusive but some of the findings may indicate a behavior change in the expected direction. Such a conclusion is supported by interview data showing that participants perceived an effect in response to both strategies.ConclusionThe findings illustrate how applied behavior analysis can be used to analyze contingencies related to the use of LVC and to design strategies for de-implementation. It also shows an effect of the targeted behaviors even though the quantitative results are inconclusive. The strategies used in this study could be further improved to target the contingencies better by structuring the feedback meetings better and including more precise feedback.

Patient request amplifies other determinants of providing low value care: A factorial survey experiment in physicians’ decision-making

“…Contrary to common assumptions among clinicians, unnecessary testing does not necessarily reassure worried patients [32]. Suggested strategies instead include different types of communication tools [33,34], including scripts for the clinicians on how to clearly describe why they are not providing a LVC practice while maintaining an empathetic approach, as well as including patient educational components in de-implementation efforts [35]. Furthermore, clearer guidelines and descriptions for physicians regarding which practices are considered LVC, in combination with feedback on use, could counterbalance the impact of patient requests [34].…”

“…Suggested strategies instead include different types of communication tools [33,34], including scripts for the clinicians on how to clearly describe why they are not providing a LVC practice while maintaining an empathetic approach, as well as including patient educational components in de-implementation efforts [35]. Furthermore, clearer guidelines and descriptions for physicians regarding which practices are considered LVC, in combination with feedback on use, could counterbalance the impact of patient requests [34]. A strategy that could counteract for the time factor (time-consuming practices less likely to be provided) could be so-called accountability tools, where clinicians are asked to provide an argument for using LVC, either written through the electronic health record or verbally to a patient [33].…”

Reducing low value care: opportunities and challenges for Choosing Wisely campaigns

“…Patey et al undertook a critical interpretative synthesis exploring whether theories of behaviour change distinguish between starting and stopping behaviours and whether they suggest different strategies for starting and stopping behaviours 6. She observed that only operant learning theory principles7 suggest different strategies for stopping behaviours (in particular principles of ‘punishment’ could inform strategies for stopping behaviours), but how best to use these principles remains unclear 8–10. She also explored whether different behaviour change techniques (BCTs) have been used in studies focussing on implementation or de-implementation.…”