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

Sara Ingvarsson; Henna Hasson; Hanna Augustsson; Per Nilsen; Ulrica von Thiele Schwarz; Ingunn Sandaker

doi:10.1186/s43058-022-00320-3

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

Implement Sci Commun. 2022 Jun 25;3(1):69. doi: 10.1186/s43058-022-00320-3.

Authors

Sara Ingvarsson¹, Henna Hasson^{2

3}, Hanna Augustsson^{2

3}, Per Nilsen⁴, Ulrica von Thiele Schwarz^{2

5}, Ingunn Sandaker⁶

Affiliations

¹ Procome Research Group, Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, 171 77, Stockholm, SE, Sweden. sara.ingvarsson@ki.se.
² Procome Research Group, Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, 171 77, Stockholm, SE, Sweden.
³ Unit for Implementation and Evaluation, Center for Epidemiology and Community Medicine (CES), Stockholm Region, 171 29, Stockholm, SE, Sweden.
⁴ Department of Health, Medical and Caring Sciences, Division of Public Health, Linköping University, Linköping, Sweden.
⁵ School of Health, Care and Social Welfare, Mälardalen University, Box 883, 721 23, Västerås, Sweden.
⁶ SCBE Research Group, Department of Behavioral Science, Faculty of Health Sciences, Oslo Metropolitan University, St. Olavs plass, P.O. Box 4, NO-0130, Oslo, Norway.

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.

Keywords: Applied behavior analysis; De-implementation; Low-value care; Physicians; Primary health care; Rule-governed behavior; Sweden; Three-term contingency.

Grants and funding

2017-00449/Forskningsrådet om Hälsa, Arbetsliv och Välfärd