Management strategies to de-implement low-value care—an applied behavior analysis

Abstract

Background There is a lack of knowledge about management strategies being used to de-implement low-value care (LVC). Furthermore, it is not clear from the current literature what mechanisms are involved in such strategies and how they can change physicians’ behaviors. Understanding the mechanisms is important for determining a strategy’s potential impact. Applied behavior analysis focuses on processes involved in increasing and decreasing behaviors. Therefore, the aim of this study is to understand what management strategies are being used to de-implement LVC and the possible mechanisms involved in those strategies, using concepts from applied behavior analysis. Method We applied a qualitative study design using an inductive approach to understand what management strategies are in use and then employed applied behavior analysis concepts to deductively analyze the mechanisms involved in them. Results We identified eight different management strategies intended to influence LVC. Five of the strategies were developed at a regional level and had the potential to influence physicians’ LVC-related behaviors either by functioning as rules on which LVC to de-implement or by initiating local strategies in each health care center that in turn could influence LVC practices. The local strategies had a stronger potential for influencing de-implementation. Conclusion Both strategies at a systemic level (regional) and on a local level (health care centers) must be considered to influence LVC-related behaviors. Strategies at the center level have a specific opportunity to impact LVC-related behaviors because they can be tailored to specific circumstances, even though some of them probably were initiated as an effect of strategies on a regional level. Using applied behavior analysis to understand these circumstances can be helpful for tailoring strategies to reduce LVC use.

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

“…One challenge in de-implementation of LVC is that few practices are LVC for all patients (7,50). For example, ordering an x-ray for patients who are being referred for surgery is still appropriate.…”

“…From a theoretical perspective, the strategies were designed to reinforce and thereby increase one behavior and, as a result, lead to a decrease in another, so-called differential reinforcement (28). Differential reinforcement has been suggested for use in de-implementation (44) but has rarely been used (50,51). However, the participants emphasized that to target the dilemma of few LVC practices being LVC for all patients, approaches are necessary that improve a behavior's precision so it is only present during the right set of circumstances.…”

“…This center was recruited from managers in primary care centers that previously participated in an explanatory interview study that aimed to describe management strategies related to the use of LVC (21). All 12 managers that participated in the previous study were invited to this study.…”

“…It has previously been used to increase staff attendance (23), improve compliance with routines (24)(25)(26), and increase emergency department efficiency (27). It has also been used to understand the mechanisms underlying management strategies to de-implementation (21). However, its potential contribution to implementation science has not been fully realized yet.…”

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

“…Thus, clinicians are influenced both by individual factors and by factors in the wider healthcare system to provide LVC, which highlights the importance of working strategically at different levels in the healthcare system to reduce LVC [7,11]. This is supported in a recent Swedish study which found that both local strategies and systemic strategies are likely required to deimplement LVC in primary healthcare in Sweden [12].…”