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Tipping the Scale of Resources : = De-Implementation of Low-Value Care from an Operant Perspective.

Record Type:	Language materials, manuscript : Monograph/item
Title/Author:	Tipping the Scale of Resources :/
Reminder of title:	De-Implementation of Low-Value Care from an Operant Perspective.
Author:	Ingvarsson, Sara.
Description:	1 online resource (83 pages)
Notes:	Source: Dissertations Abstracts International, Volume: 84-10, Section: B.
Contained By:	Dissertations Abstracts International84-10B.
Subject:	Infections. -
Online resource:	click for full text (PQDT)
ISBN:	9798377694502

Tipping the Scale of Resources : = De-Implementation of Low-Value Care from an Operant Perspective.
Ingvarsson, Sara.

Tipping the Scale of Resources :De-Implementation of Low-Value Care from an Operant Perspective. - 1 online resource (83 pages)

Source: Dissertations Abstracts International, Volume: 84-10, Section: B.

Thesis (Ph.D.)--Karolinska Institutet (Sweden), 2023.

Includes bibliographical references

Background: The overarching goal within the field of implementation science is to generateknowledge that can contribute to bridging the gap between research and practice. Moststudies focus on how to implement research findings, with the aim of using evidence-basedinterventions. However, it has increasingly been recognized that working in accordance withevidence not only requires implementation of research findings but also the "opposite," i.e.,de-implementation of so called low-value care (LVC).LVC makes up between 11 and 30 percent of all care provided, depending on type of LVCand study population. To address the issue of LVC, several guidelines have been published -but this does not seem to be sufficient to influence its use. Like implementation, deimplementation of LVC requires behavior changes among professionals within health care.The difference is that whereas implementation most often involves increasing certainbehaviors, de-implementation involves both decreasing and increasing behaviors. Inimplementation, strategies are designed by identifying factors influencing behavior,identifying theoretically or empirically validated change methods to address those factors,and developing or choosing strategies that use those methods. However, it is not known whatfactors influence use and de-implementation of LVC. It is also not known if the sametheories, models, and frameworks are relevant for de-implementation as for implementationor what de-implementation strategies are effective. Applied behavior analysis (ABA) is theonly theory within psychology and sociology that discriminates between processes forincreasing and decreasing behavior suggesting that this could be a valuable theory to use tounderstand factors influencing the use of LVC and to design de-implementation strategies.The overarching aim of the thesis was to generate new knowledge and insights concerninguse and de-implementation of LVC. To achieve this aim, the four studies of the thesis havehad the following objectives:-To identify factors that influence use and de-implementation of LVC (Study I).-To understand why physicians in primary care use LVC (Study II).-To understand which management strategies are being used to de-implement LVCand possible mechanisms for those strategies using concepts from ABA (Study III).-To demonstrate how ABA can be used to understand contingencies related to use ofLVC and how de-implementation strategies can be developed by arranging alternativecontingencies (Study IV).Method:Four studies were conducted: one scoping review, one qualitative study withphysicians within primary care, using a grounded theory approach, one qualitative study withmanagers and key stakeholders within primary care on management strategies for deimplementation, and one intervention study where two strategies for de-implementation weredeveloped based on applied behavior analysis to reduce use of unnecessary X-ray examinations for knee arthrosis.Results: The scoping review showed factors influencing the use and de-implementation ofLVC related to both the outer and the inner context, the professionals, the LVC itself, theprocess of de-implementation, and the patients and their relatives. The qualitative studyshowed three factors that influenced use of LVC: uncertainty and disagreement about whatnot to do, perceived pressure from others, and a desire to do something for the patients. Thequalitative study on management strategies showed eight different management strategies:financial systems, scorecards, quality assurance systems, guidelines, lectures, local processstrategies, discussions about guidelines, and local lectures. The intervention study providedan analysis of factors influencing the unnecessary use of X-ray examinations for kneearthrosis: a rule stating that X-ray examinations are beneficial for diagnosing arthrosis andpatients expressing expectations of being referred to an X-ray examination and showingappreciation for being referred for one. Two strategies were developed: A lecture aiming atintroducing a new rule stating that X-ray examinations are not beneficial for diagnosingarthrosis and feedback meetings providing consequences encouraging diagnosis of arthrosiswithout the use of an X-ray examination. The strategies were perceived as helpful by thephysicians who participated in the study.Conclusion: This thesis has provided knowledge about factors that influenced use of LVC aswell as an understanding of how strategies for de-implementation could be developed.Factors external to the health care organizations seem to create a demand for LVC, mostlyinadvertently through financial conditions that provide payment or reduce costs in relation toLVC. Factors within health care organizations, such as lack of continuity and standardordering sets for laboratory tests, can also influence use of LVC, as can factors in theimmediate environment of the individual health care professionals, such as problems withguidelines, pressure from others, and a desire to do something for patients.Thus far, de-implementation strategies developed at a local level seem to have the greatestpotential to influence use of LVC. These strategies can be better adapted to local contextualfactors. One way of doing so is by using ABA to understand local contextual factors or inABA terms - contingencies. Strategies that influence processes, such as improved continuityor removing unnecessary laboratory tests from standard ordering sets, also have the potentialto reduce use of LVC. Lastly, there is a lack of strategies involving factors external to thehealth care organizations, even though these factors influence use of LVC.

Electronic reproduction.
Ann Arbor, Mich. :
ProQuest,
2024

Mode of access: World Wide Web

ISBN: 9798377694502Subjects--Topical Terms:

882242
Infections.
Index Terms--Genre/Form:

554714
Electronic books.

Tipping the Scale of Resources : = De-Implementation of Low-Value Care from an Operant Perspective.
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Like implementation, deimplementation of LVC requires behavior changes among professionals within health care.The difference is that whereas implementation most often involves increasing certainbehaviors, de-implementation involves both decreasing and increasing behaviors. Inimplementation, strategies are designed by identifying factors influencing behavior,identifying theoretically or empirically validated change methods to address those factors,and developing or choosing strategies that use those methods. However, it is not known whatfactors influence use and de-implementation of LVC. It is also not known if the sametheories, models, and frameworks are relevant for de-implementation as for implementationor what de-implementation strategies are effective. Applied behavior analysis (ABA) is theonly theory within psychology and sociology that discriminates between processes forincreasing and decreasing behavior suggesting that this could be a valuable theory to use tounderstand factors influencing the use of LVC and to design de-implementation strategies.The overarching aim of the thesis was to generate new knowledge and insights concerninguse and de-implementation of LVC. To achieve this aim, the four studies of the thesis havehad the following objectives:-To identify factors that influence use and de-implementation of LVC (Study I).-To understand why physicians in primary care use LVC (Study II).-To understand which management strategies are being used to de-implement LVCand possible mechanisms for those strategies using concepts from ABA (Study III).-To demonstrate how ABA can be used to understand contingencies related to use ofLVC and how de-implementation strategies can be developed by arranging alternativecontingencies (Study IV).Method:Four studies were conducted: one scoping review, one qualitative study withphysicians within primary care, using a grounded theory approach, one qualitative study withmanagers and key stakeholders within primary care on management strategies for deimplementation, and one intervention study where two strategies for de-implementation weredeveloped based on applied behavior analysis to reduce use of unnecessary X-ray examinations for knee arthrosis.Results: The scoping review showed factors influencing the use and de-implementation ofLVC related to both the outer and the inner context, the professionals, the LVC itself, theprocess of de-implementation, and the patients and their relatives. The qualitative studyshowed three factors that influenced use of LVC: uncertainty and disagreement about whatnot to do, perceived pressure from others, and a desire to do something for the patients. Thequalitative study on management strategies showed eight different management strategies:financial systems, scorecards, quality assurance systems, guidelines, lectures, local processstrategies, discussions about guidelines, and local lectures. The intervention study providedan analysis of factors influencing the unnecessary use of X-ray examinations for kneearthrosis: a rule stating that X-ray examinations are beneficial for diagnosing arthrosis andpatients expressing expectations of being referred to an X-ray examination and showingappreciation for being referred for one. Two strategies were developed: A lecture aiming atintroducing a new rule stating that X-ray examinations are not beneficial for diagnosingarthrosis and feedback meetings providing consequences encouraging diagnosis of arthrosiswithout the use of an X-ray examination. The strategies were perceived as helpful by thephysicians who participated in the study.Conclusion: This thesis has provided knowledge about factors that influenced use of LVC aswell as an understanding of how strategies for de-implementation could be developed.Factors external to the health care organizations seem to create a demand for LVC, mostlyinadvertently through financial conditions that provide payment or reduce costs in relation toLVC. Factors within health care organizations, such as lack of continuity and standardordering sets for laboratory tests, can also influence use of LVC, as can factors in theimmediate environment of the individual health care professionals, such as problems withguidelines, pressure from others, and a desire to do something for patients.Thus far, de-implementation strategies developed at a local level seem to have the greatestpotential to influence use of LVC. These strategies can be better adapted to local contextualfactors. One way of doing so is by using ABA to understand local contextual factors or inABA terms - contingencies. Strategies that influence processes, such as improved continuityor removing unnecessary laboratory tests from standard ordering sets, also have the potentialto reduce use of LVC. Lastly, there is a lack of strategies involving factors external to thehealth care organizations, even though these factors influence use of LVC.
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