Ingvarsson Sara, Sandaker Ingunn, Nilsen Per, Hasson Henna, Augustsson Hanna, von Thiele Schwarz Ulrica
Procome Research Group, Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden.
Department of Behavioral Science, Faculty of Health Sciences, Oslo Metropolitan University, Oslo, Norway.
Front Health Serv. 2023 Feb 28;3:1099538. doi: 10.3389/frhs.2023.1099538. eCollection 2023.
Implementation science has traditionally focused on the implementation of evidence-based practices, but the field has increasingly recognized the importance of addressing de-implementation (i.e., the process of reducing low-value care). Most studies on de-implementation strategies have used a combination of strategies without addressing factors that sustain the use of LVC and there is a lack of information about which strategies are most effective and what mechanisms of change might underlie these strategies. Applied behavior analysis is an approach that could be a potential method to gain insights into the mechanisms of de-implementation strategies to reduce LVC. Three research questions are addressed in this study: What contingencies (three-term contingencies or rule-governing behavior) related to the use of LVC can be found in a local context and what strategies can be developed based on an analysis of these contingencies?; Do these strategies change targeted behaviors?; How do the participants describe the strategies' contingencies and the feasibility of the applied behavior analysis approach?
In this study, we used applied behavior analysis to analyze contingencies that maintain behaviors related to a chosen LVC, the unnecessary use of x-rays for knee arthrosis within a primary care center. Based on this analysis, strategies were developed and evaluated using a single-case design and a qualitative analysis of interview data.
Two strategies were developed: a lecture and feedback meetings. The results from the single-case data were inconclusive but some of the findings may indicate a behavior change in the expected direction. Such a conclusion is supported by interview data showing that participants perceived an effect in response to both strategies.
The findings illustrate how applied behavior analysis can be used to analyze contingencies related to the use of LVC and to design strategies for de-implementation. It also shows an effect of the targeted behaviors even though the quantitative results are inconclusive. The strategies used in this study could be further improved to target the contingencies better by structuring the feedback meetings better and including more precise feedback.
实施科学传统上侧重于循证实践的实施，但该领域越来越认识到解决去实施（即减少低价值医疗的过程）的重要性。大多数关于去实施策略的研究都采用了多种策略的组合，而没有考虑维持低价值医疗使用的因素，并且缺乏关于哪些策略最有效以及这些策略背后可能的改变机制的信息。应用行为分析是一种可能有助于深入了解减少低价值医疗的去实施策略机制的潜在方法。本研究解决了三个研究问题：在当地环境中可以发现哪些与低价值医疗使用相关的意外情况（三项意外情况或规则支配行为），以及基于对这些意外情况的分析可以制定哪些策略？；这些策略是否会改变目标行为？；参与者如何描述策略的意外情况以及应用行为分析方法的可行性？
在本研究中，我们使用应用行为分析来分析维持与选定的低价值医疗相关行为的意外情况，即在初级保健中心对膝关节骨性关节炎不必要地使用x光。基于此分析，使用单案例设计和访谈数据的定性分析来制定和评估策略。
制定了两种策略：一次讲座和反馈会议。单案例数据的结果尚无定论，但一些发现可能表明行为朝着预期方向发生了变化。访谈数据支持了这一结论，表明参与者认为这两种策略都产生了效果。
研究结果说明了应用行为分析如何可用于分析与低价值医疗使用相关的意外情况，并设计去实施策略。即使定量结果尚无定论，它也显示了目标行为的效果。本研究中使用的策略可以通过更好地组织反馈会议并提供更精确的反馈来进一步改进，以更好地针对意外情况。
