Article IV. Healthcare professionals’ opinions, barriers and

5. Results

5.2. Full text of articles

5.2.4. Article IV. Healthcare professionals’ opinions, barriers and

Osorio D (contacting author), Ribera A, Solans M, Arroyo L, Ballesteros M, Romea S. Healthcare professionals’ opinions, barriers and facilitators towards low-value clinical practices in the hospital setting. Gaceta sanitaria. 2019. 34 (5):459–467. DOI: https://doi.org/10.1016/j.gaceta.2018.11.007.

Impact factor 2019: 1,564

GacSanit.2020;34(5):459–467

OriginalArticle

Healthcareprofessionals’opinions,barriers andfacilitators towardslow-valueclinicalpracticesin thehospitalsetting

DimelzaOsorioâ,b,c,^∗, AidaRibera^b,d, MaiteSolans-Domènech^b,e, LilianaArroyo-Moliner^f, MónicaBallesterosâ,c,SoledadRomea-Lecumberriâ,c

aValld’HebronUniversityHospital,Barcelona,Spain

bCIBERdeEpidemiologíaySaludPública(CIBERESP),Spain

cHealthServicesResearchGroup,InstitutdeRecercaValld’Hebron,Barcelona,Spain

dCardiovascularEpidemiologyUnit,InstitutdeRecercaValld’Hebron,Barcelona,Spain

eAgènciadeQualitatiAvaluacióSanitàriesdeCatalunya(AQuAS),Barcelona,Spain

fInstitutodeInnovaciónSocial,Dpto.CienciasSociales,ESADEBusiness&LawSchool,Barcelona,Spain

a r t i c l e i n f o

Articlehistory:

Received3September2018 Accepted26November2018 Availableonline10February2019 Keywords:

Objective:Toexplorehealthcareprofessionals’opinionsaboutlow-valuepractices,identifypracticesof thiskindpossiblypresentinthehospitalandbarriersandfacilitatorstoreducethem.Low-valuepractices includethosewithlittleornoclinicalbenefitthatmayharmpatientsorleadtoawasteofresources.

Method:Usingamixedmethodology,wecarriedoutasurveyandtwofocusgroupsinatertiaryhospital.

Inthesurvey,weassesseddoctors’agreement,subjectiveadherenceandperceptionofusefulnessof 134recommendationstoreducelow-valuepracticesfromlocalandinternationalinitiatives.Wealso identifiedlow-valuepracticespossiblypresentinthehospital.Inthefocusgroupswithprofessionals fromsurgicalandmedicalfields,usingaphenomenologicalapproach,weidentifiedadditionallow-value practices,barriersandfacilitatorstoreducethem.

Results:169doctorsof25specialtiesparticipated(responserate:7%-100%).Overallagreementwith rec-ommendations,subjectiveadherenceandusefulnesswere83%,90%and70%,respectively.Low-value practicesform22recommendations(16%)wereconsideredaspossiblypresentinthehospital.Inthe focusgroups,theprofessionalsidentifiedsevenmore.Defensivemedicineandscepticismdueto contra-dictoryevidencewerethemainbarriers.Facilitatorsincludedgoodleadershipandcoordinationbetween professionals.

Conclusions:Highagreementwithrecommendationstoreducelow-valuepracticesandhighperception ofusefulnessreflectgreatawarenessoflow-valuecareinthehospital.However,thereareseveralbarriers toreducethem.Interventionstoreducelow-valuepracticesshouldfosterconfidenceindecision-making processesbetweenprofessionalsandpatientsandprovidetrustedevidence.

Opiniones,barrerasyfacilitadoresdelosprofesionalesdelasaludhacialas prácticasclínicasdepocovalorenelámbitohospitalario

Palabrasclave:

Objetivo:Explorarlasopinionesdeprofesionalessanitariossobrelasprácticasdepocovalor,identificar aquellasposiblementepresentesenelhospitalylasbarrerasylosfacilitadoresparareducirlas.Las prác-ticasdepocovalorincluyenaquellasconpocobeneficioclínicoquepuedenperjudicaralospacienteso desperdiciarrecursos.

Método:Usandounametodologíamixtasellevaronacabounaencuestayvariosgruposfocalesenun hospitalterciario.Enlaencuestaseevaluóelgradodeacuerdo,laadherenciasubjetivaylapercepción deutilidadde134recomendacionesparareducirlasprácticasdepocovalordeiniciativaslocalese internacionales,yseidentificaronaquellasquepodríanestarrealizándoseenelhospital.Endosgrupos focalesconprofesionalesdecamposmédicosyquirúrgicos,utilizandounenfoquefenomenológico,se identificaronprácticasdepocovaloradicionales,barrerasyfacilitadoresparareducirlas.

Resultados:Enlaencuestaparticiparon169médicosde25especialidades(tasaderespuesta:7-100%).

Elacuerdoconlasrecomendaciones,laadherenciasubjetivaylautilidadfuerondel83%,el90%yel70%, respectivamente.Seidentificaronprácticasdepocovalorde22recomendaciones(16%)posiblemente presentesenelhospital.Enlosgruposfocalesseidentificaronsieteprácticasdepocovaloradicionales;

lamedicinadefensivayelescepticismodebidoaevidenciacontradictoriacomoprincipalesbarreras;y unbuenliderazgoylacoordinaciónentreprofesionalescomofacilitadores.

∗ Correspondingauthor.

E-mailaddress:dimelzaosorio@gmail.com(D.Osorio).

https://doi.org/10.1016/j.gaceta.2018.11.007

460 D.Osorioetal./GacSanit.2020;34(5):459–467

Conclusiones:Elaltogradodeacuerdoconlasrecomendacionesparareducirlasprácticasdepocovalor ylaaltapercepcióndeutilidadreflejanunagranconcienciaciónsobreesteproblemaenelhospital.

Sinembargo,existennumerosasbarrerasparaeliminarlas.Lasintervencionesparareducirlasdeberían fomentarlaconfianza enlatomadedecisionesentreprofesionalesypacientes,yproporcionaruna evidenciaconfiable.

Introduction

Low-valuepracticesincludedoingtestsandtreatmentsin con-textswithlittleornoclinicalbenefit.Theyareoflow-valuebecause:

1)theydomoreharmthangood;or2)lackproveneffectiveness;

or3)areunnecessarybecausetheydonotmodifyclinical decision-making;or4)areinterventionsproviding littleornobenefit in healthat highcosts.^1–4 Allinterventionsof thiskindshouldbe avoided,becausetheythreatenpatients’safetyandthequalityand sustainabilityofhealthsystems.^5–8

Manyinitiativesworldwidehavebeenestablishedtoaddress low-value practices. Someof thebest knownare theChoosing WiselyCampaigns,wherescientificsocietiesprovide recommen-dationstoreducepracticeswhosenecessityshouldbediscussed.

Thesecampaigns have taken placein severalcountries, includ-ingtheUnitedStatesofAmerica,Canada,AustraliaandItaly.^9–12 Initiativesinothercountrieshaveadoptedsomeofthese recom-mendationsanddevelopedseveralmore,forinstance,theSpanish initiativesEssencial,¹³andCommitmenttoqualityoftheSpanish scientificsocieties.¹⁴

Eventhoughproposingrecommendationstoreducelow-value practicesis abigfirststep,theirdetectionatlocal settingsand understandinghealthprofessionals’viewsonthisproblemare cru-cialindevelopingeffectiveinterventionstoreducethem.Several studieshaveassesseddoctors’perspectivesabouttheconceptof low-value care. However, almost all them have taken place in theprimarycare setting,^15–19 and scarcestudieshave analysed thehospitalsetting,wherehealthspendingishigher.Studiesin thehospitalsettinghaveassessedtheconceptoflow-valuecare ingeneral,²⁰ orconsulted theopinionof directors anddivision chiefs.^21,22Yet,asfarasweknow,littleisknownaboutbarriers andfacilitatorsinthissetting.

Theaimsofthisstudyweretoexplorehealthcare profession-als’opinionsaboutlow-valuepractices,identifypracticesofthese kindpossiblypresentinthehospitalandbarriersandfacilitatorsto reducethem.

Method

Studydesignandsetting

Weusedamixedmethodologythroughanonlinesurveyand twofocusgroups.ThestudytookplacebetweenJanuary2016and June2017intheValld’HebronUniversityHospital,atertiary uni-versityhospitalinSpainwithmorethan1000beds.Itwasapproved bytheValld’HebronClinicalResearchEthicsCommittee.

Intheon-linesurveyweassesseddoctors’opinionsaboutaset ofrecommendationstoreducelow-valuepractices,andpracticesof thiskindpossiblypresentinthehospital.Surveyresultswere com-plementedwithfocusgroupswithhealthprofessionalstoidentify additionallow-valuepracticespossiblypresentinthehospitaland barriersandfacilitatorstoreducethem.

Onlinesurvey

1)Selectionofrecommendationtoreducelow-valuepractices TherecommendationswereobtainedfromDianaHealth.com, an open access on-line database of appraisals about health-careinterventionsconsideredoflowvaluebyseveralinitiatives worldwide.²³Fromtherecommendationsavailableinthedatabase, we randomly preselected200 and then, we selectedfrom five anduptotenrecommendationsperspecialtywherethe interven-tionandthespecialtyinreferencewereavailableinthehospital.

Whenrecommendationsrelatedtothesamepopulationandthe same intervention wereselected, we keptonly one, preferably from a local initiative. When a given specialty was found to havelessthanfiverecommendations,thedatabasewasconsulted again.

2)Survey’ssampleandprocess

Thesurveywasaimedatalldoctorsfromthespecialtiesrelated totheincludedrecommendations,residentswereexcluded.

Inthequestionnaire,participantswereaskedtospecifywhether theywerespecialistsorresidentsandtheirspecialty.Nopersonal informationwasasked.Accordingtodoctors’specialty,theform displayedalistof5to10recommendationsandfourquestions about them that are shown in Table1.The questionnaire was testedbeforecollectingdata;completiontimewasbetween 10-20minutes.

Wesentanemailtoinvitedoctorstoparticipateinthesurvey explaining the purpose of the study and a link to the ques-tionnaire.Tworeminders weresentoneand two monthslater.

Participation was anonymous, voluntary and not economically compensated.

3)Surveyanalysis

Doctors’ opinion was assessed through the following out-comes:agreement,subjectiveadherence,reasonsfordisagreement and usefulness.Outcomesdefinition areshown in Table 1.The unitofanalysiswasdoctors’response. Wecompared resultsby type of specialty: medical and surgical specialtiesand by type ofintervention infourcategories:diagnosticimages,diagnostic laboratorytestsand procedures, pharmacologicaltherapies and non-pharmacologicaltherapies.

Thelow-valuepracticespossiblypresentinthehospitalwere identified througha composite outcomedefined asthose prac-ticesfromrecommendationswithanagreementover70%anda subjectiveadherenceunder70%. Usefulnesswasnot takeninto accountin thecomposite outcomesince wewereinterested in identifying low-value practices, even when doctors may con-sidertherecommendationasnotuseful.Datawasanalysedwith SPSSv.23..

D.Osorioetal./GacSanit.2020;34(5):459–467 461 Table1

Surveyquestionnaireandoutcomedefinition.

Surveyquestionnaire Outcomedefinition

Question Options Name Concept Operativedefinition

1.Doyouagreewiththis recommendation?

Yes No

Agreement Whetherrespondent

agreesornottowhatis statedinthe theHospital,eitherinyour departmentorinothers?

Numberbetween0and100% Subjectiveadherence Adherenceinthe hospitalaccordingto youropinion,whatisthe reason?

Multiplechoices:

-Newevidencearosecontradicting thisrecommendation

-Therecommendationdoesnot applyinthehospitalsetting -Therecommendationisnot feasibleinthehospitalsetting -Otherreasons

4.Howusefuldoyou considerthis spiteofagreeingwithit

useful+veryuseful/n

1)Focusgroups’sampleandprocess

Onefocusgroupsincludedprofessionalsfromthesurgicalfield and theotherfromthemedical field. Aconveniencesample of 20participants(10pergroup)wasselectedfromthestaffdatabase usingthefollowingcriteria:evendistributionaccordingtosexand age(<35,35-50and>50years)andatleastoneactiveresearcher, onespecialistindiagnostictestsandonenurseshouldbeincluded.

Wesentaninvitationletterbyemailtotheparticipants.Incases wheretheinvitationwasdeclined,welookedforanother candi-datefollowingthesameselectioncriteria.Thetwogroupsworked inface-to-facesinglesessionsof90minuteseach.Beforethe ses-sion,alltheparticipantsgaveverbalconsenttoparticipateinthe studyandtoaudio-recordthesession.Oneoftheresearchers(LAM), anexternalexpertwithovertenyearsofexperiencein qualita-tiveresearchmethodology,conductedthesessions,andasecond researcher(MSD),recordedthemandmadenotes.Noneofthem knewtheparticipants.

A pre-defined discussion guide available in Table I intheonlineAppendixwasusedinthesession.Thediscussion includedexamplesoflow-valuepractices;individual,institutional and social factors leading to low-value practices or difficulties whentryingtoavoidthem;andfactorsthathelptoreduceoravoid low-valuepractices.

2)Focusgroupsanalysis

We analysed the audio-records and notes of the two ses-sionswithaphenomenologicalapproach,usingtheparadigmof groundedtheory.^24,25LAMtranscribed audio-recordsandnotes, keepingparticipantsnamesandspecialtiesanonymised.

Verbatimwerecodedusingamatrixproposedaprioribythe AgencyforHealthQualityandAssessmentofCatalonia,basedona similarstudycarriedoutinprimarycare(inprocessofpublication).

Inafirstphase,weusedanopencoding,creatinglabelstoidentify topics;andthenweclassifiedthemasbarriersorfacilitators.Ina secondphaseweusedaxialcodingtorelatetopicsinconstructs

calledcategories.Thesecategoriesweregroupedintofourlevels:

micro(relatedtoindividuals:patientsandhealthprofessionals), meso(relatedtoDoctor-Patientrelationshipandmanagementand processesintheinstitution),macro(relatedtotheHealthsystem) andexternalfactors(outsidetheHealthsystem).

All researchers discussed and reviewed the organisation of themes until consensus was achieved. The analysis included a comparison betweenmedicaland surgicalspecialties.Data was analysed withthesoftwareAtlas.Ti v.6.Theresultsand conclu-sionsoftheanalysiswerereturnedtoparticipantsforcomment andfeedback.

Results Survey

From 2475recommendations and appraisals toreduce low-value practices available in DianaHealth.com, we included 134recommendations applicable interventionsavailable in our hospital: 65 (49%) on diagnostic tests, 53 (40%) on phar-macological therapies and 16 (12%) on non-pharmacological therapies,includingsurgeryandphysicaltherapy.The recommen-dations,specialty,typeofintervention,andsourceareshownin TableIIintheonlineAppendix.

Atotalof169doctorsfrom25specialtiesrespondedthesurvey.

Theygavetheiropinionon127ofthe134recommendations(total ofresponses=1183).Responseratebyspecialtyrangedfrom7%

to100%(FigureIintheonlineAppendix),being28%and18%in medicalandsurgicalspecialtiesrespectively.

1)Agreement

Figure1Ashowsaggregatedresultsofdoctors’agreementby specialtyand type ofintervention. Theproportion of responses where doctorsagreedwitha recommendationwasover 70%in alltypeofrecommendations,exceptinthoseondiagnostictests in thegroupofsurgicalspecialties.For example, oneoutof 11 urologists(agreementof9%)agreedonarecommendationabout prostatebiopsyforhistologicalconfirmationifclinicalsuspicionof

462 D.Osorioetal./GacSanit.2020;34(5):459–467

Part A. Agreement with the recommendations: percentage and number of responses agreeing with the recommendation

Part B. Subjective adherance: median and interquartile range of percentage of adherance to the recommendation according to doctors opinion

Part C. Usefulness: percentage and number of responses considering the recommendation as useful or very useful 100%

Figure1.Agreement(partA),subjectiveadherence(partB),andusefulness(partC)ofrecommendationsbytypeofspecialtyandtypeofintervention.

prostatecancerishigh(resultsofindividualrecommendationsare showninTableIIIintheonlineAppendix).

In 42 (33%) recommendations, at least one doctor did not agreewiththerecommendation.Reasonsofdisagreementwere:

newevidencearosecontradictingthisrecommendation(9outof 66responses=13%);recommendationdidnotapplyinthehospital setting(12%);andrecommendationwasnotfeasibleinthe hos-pitalsetting(5%).Otherreasonswereexplainedin70%(n=46)of cases;theywererelatedmainlytotheuseofatesttoorientatethe treatmentandconcernsaboutmissingtherightdiagnosis.

2)Subjectiveadherence

Figure1Bshowsaggregatedresultsofsubjectiveadherence.

Themedianpercentageofsubjectiveadherencewasover70%inall

typeofrecommendations,exceptinthoseondiagnosticimagesin thegroupofsurgicalspecialties.

3)Usefulnessofrecommendations

Figure 1C shows aggregated results of usefulness. In total, in 70% of responses,participants considered the recommenda-tionsasusefulorveryuseful.However,itwasunder70%inall typeofinterventionsinthesurgicalspecialties.Forexample,two outof14specialistsconsideredarecommendationadvisingnotto useinjectabledrugslocallyfornonspecificlowbackpainasuseful orveryuseful(usefulness:14%).

4)Low-valuepracticespossiblypresentinthehospital

Practicesfrom22recommendationshadanagreementof70%

ormoreandsubjectiveadherenceunder70%;theyrepresent16%

D.Osorioetal./GacSanit.2020;34(5):459–467 463

Figure2.Compositeoutcome:low-valuepracticespossiblypresentinthehospitalbytypeofspecialtyandtypeofintervention.

ofthe134recommendations.Thedistributionofthesepracticesby specialtyandtypeofinterventionisshownintheFigure2.In14 outofthe22(64%)recommendationsusefulnesswas70%ormore.

Focusgroup

Eightprofessionals participatedin thegroupofmedical spe-cialties andseven inthe surgicalgroup.Five doctorscouldnot attendthesession.Thecompositionofeachgroupisdescribedin TableIVintheonlineAppendix.

1)Low-valuepracticespossiblypresentinthehospital

Participantsgavesevenexamplesoflow-valuepracticespresent inthehospitalthataresummarisedinTable2.

2)Barriersforreducinglow-valuepractices

Mostofthequotationswereaboutbarriers.Severaltopicswere aboutindividuals(microlevel)andinteractionsbetween profes-sionalsandtheorganisation(mesolevel).Atthemicrolevel,the mostcommonbarrier wasrelated to thecategory ofdefensive medicine(Table3):“...inmycase,isbettertohaveonetestmore thanonetestmissing.Because,ifyoumisssomethingthatmayhave dramaticconsequences,forinstanceanundetectedrecurrence.So, youendedupaskingforthattest.Eventhoughyouknow...you are95%sureyouwillnotfindanythingbad”.

Regarding scientific evidence, participants considered evidence-based resources excessive and sometimes outdated and even contradictory, leading to a low confidence and low adherence to clinical recommendations. Patients’ literacy and knowledge was considered as a barrier when expert patients demandspecificteststhatdoctorsmayconsideroflow-valueina givencontext.

Atthemesolevel,lackleadership,lackofinteractionbetween professionalsandlowuniformityindoctors’activitieswere per-ceivedasimportantbarriers;forinstance:duplicityindiagnostic testsbetweendepartmentsduringfollow-up,orcriteriavariability whenorderingdiagnostictestsorprescribingtreatments. Duplic-itywasclassifiedasabarrieratthemesolevelbecausemostofthe casesitisrelatedtolackofcoordinationataninstitutionallevel;

however,thereareduplicitiesthatmayberelatedto profession-als’misuseoftests,forinstancewhentestsaremadeunnecessarily often,e.g.themeasurementofthyroid-stimulatinghormonebefore 6weeksaftermodifyingthedose,ortakingdailysamplingincritical patients(thatmayinduceanaemiainelderly).

Whencomparingbetweenmedicalandsurgicalgroups, medi-calspecialtiesmentionedtopicsthatdidnotappearinthesurgical group,for instancethemanagement ofuncertaintyorexcessof

information(infoxication).Ontheotherhand,surgicalspecialties expressedconcernsaboutlegalsupportfromtheinstitutionthat werenotmentionedinthemedicalspecialties’group(Table3).

3)Facilitatorsforreducinglow-valuepractices

Allthefacilitatorssuggestedbytheparticipantswererelatedto themeso-levelbarriers.Discussionwasmostlyaboutmanagement andleadershipwhereteamworkwasconsideredasafacilitator:

“...Youwillalwaysfind20%ofpeoplethatwillnotagree with you.teamworkisessential.becauseifoneteammemberstartsto turnthewheel,andanotherteammemberdoesthesame,aftera whilethewheelwillturnautomatically”.Seemoreexamplesof verbatiminTablesVandVIintheonlineAppendix.Someverbatim werespecificimprovementproposalsthatmayreducelow-value practices(Table4).

Discussion

Keyfindingsinrelationtopreviousliterature

Theaimsofthisstudyweretoexplorehealthcare profession-als’opinionsaboutlow-valuepractices,identifypracticesofthese kindpossiblypresentinthehospitalandbarriersandfacilitatorsto reducethem.

Specialistsshowedanacceptableagreementwith134 recom-mendationsaimedtoreducelow-valuepractices(83%),andinmost responsestherecommendationswereconsideredusefulorvery

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