Why do they do it? A grounded theory study of the use of low-value care among primary health care physicians

Abstract

Background The use of low-value care (LVC) is widespread and has an impact on both the use of resources and the quality of care. However, few studies have thus far studied the factors influencing the use of LVC from the perspective of the practitioners themselves. The aim of this study is to understand why physicians within primary care use LVC. Methods Six primary health care centers in the Stockholm Region were purposively selected. Focus group discussions were conducted with physicians (n = 31) working in the centers. The discussions were coded inductively using a grounded theory approach. Results Three main reasons for performing LVC were identified. Uncertainty and disagreement about what not to do was related to being unaware of the LVC status of a practice, guidelines perceived as conflicting, guidelines perceived to be irrelevant for the target patient population, or a lack of trust in the guidelines. Perceived pressure from others concerned patient pressure, pressure from other physicians, or pressure from the health care system. A desire to do something for the patients was associated with the fact that the visit in itself prompts action, symptoms to relieve, or that patients' emotions need to be reassured. The three reasons are interdependent. Uncertainty and disagreement about what not to do have made it more difficult to handle the pressure from others and to refrain from doing something for the patients. The pressure from others and the desire to do something for the patients enhanced the uncertainty and disagreement about what not to do. Furthermore, the pressure from others influenced the desire to do something for the patients. Conclusions Three reasons work together to explain primary care physicians’ use of LVC: uncertainty and disagreement about what not to do, perceived pressure from others, and the desire to do something for the patients. The reasons may, in turn, be influenced by the health care system, but the decision nevertheless seemed to be up to the individual physician. The findings suggest that the de-implementation of LVC needs to address the three reasons from a systems perspective.

Reducing low-value care: what can we learn from eight de-implementation studies in the Netherlands?

“…Patient expectations and a lack of time to turn these around are frequently reported barriers to reducing low-value care. [29][30][31][32][33][34][35][36][37] In our eight projects, a fear of malpractice was not identified as a barrier, contrary to several other studies from the USA. 29 33 This might indicate that malpractice claims have a smaller influence in the Netherlands.…”

Applying the behavior change wheel to design de-implementation strategies to reduce low-value statin prescription in primary prevention of cardiovascular disease in primary care

“…The identified determinants are in line with other determinants identified or reported in previous studies regarding determinants of low-value practice and of low-value pharmacological prescription. For example, uncertainty due to the variability and/or conflict of the guidelines with respect to the recommended practice, the pressures and demands on the part of the patients, the need for rapid and decisive action in response to the reasons for consultation and the desire to please the patients have been identified as interconnected motives that generally justify maintaining low-value practices ( 27 ). With regard to inappropriate prescription of drugs in general, a systematic review published by Anderson et al ( 28 ), in which the barriers and facilitators for inappropriate prescription were explored, highlights four aspects that facilitate or hinder professionals' decisions when faced with a possible pharmacological prescription: first, awareness of the problem, i.e., knowing to what extent the clinical practice of each professional conforms to what is recommended in CPGs, as well as knowing the consequences of treating a patient pharmacologically or not.…”

Does de-implementation of low-value care impact the patient-clinician relationship? A mixed methods study

“…The vignettes also (intentionally) presented scenarios as patient requests for services that the clinician denied based on being categorized as LVC. Although patient request or demand for LVC is common [ 21 , 22 ], there are other drivers of LVC utilization. Finally, many real-world patient-clinician interactions around LVC are brief in duration.…”