Ingvarsson Sara, Augustsson Hanna, Hasson Henna, Nilsen Per, von Thiele Schwarz Ulrica, von Knorring Mia
Procome Research Group, Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, SE-171 77, Stockholm, Sweden.
Unit for Implementation and Evaluation, Center for Epidemiology and Community Medicine (CES), SE-171 29, Stockholm, Stockholm Region, Sweden.
Implement Sci. 2020 Oct 21;15(1):93. doi: 10.1186/s13012-020-01052-5.
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.
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.
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.
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.
低价值医疗（LVC）的使用十分普遍，对资源利用和医疗质量均有影响。然而，迄今为止，很少有研究从从业者自身的角度探讨影响LVC使用的因素。本研究旨在了解基层医疗中的医生为何使用LVC。
有目的地选取了斯德哥尔摩地区的6家基层医疗中心。对在这些中心工作的医生（n = 31）进行了焦点小组讨论。采用扎根理论方法对讨论内容进行归纳编码。
确定了实施LVC的三个主要原因。对于不应该做什么存在不确定性和分歧，这与不了解某种医疗行为的LVC状态、认为指南相互冲突、认为指南与目标患者群体无关或对指南缺乏信任有关。感受到来自他人的压力包括患者的压力、其他医生的压力或医疗系统的压力。想要为患者做点什么与就诊本身促使采取行动、缓解症状或安抚患者情绪的事实有关。这三个原因相互依存。对于不应该做什么的不确定性和分歧使得应对来自他人的压力以及克制为患者做某些事情变得更加困难。来自他人的压力和为患者做点什么的愿望加剧了对于不应该做什么的不确定性和分歧。此外，来自他人的压力影响了为患者做点什么的愿望。
三个原因共同作用，解释了基层医疗医生使用LVC的情况：对于不应该做什么的不确定性和分歧、感受到来自他人的压力以及为患者做点什么的愿望。这些原因可能反过来受到医疗系统的影响，但决策似乎仍然取决于个体医生。研究结果表明，减少LVC的使用需要从系统角度解决这三个原因。
