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Background Withdrawal of reimbursement for low-value care through a policy change, ie, active disinvestment, is considered a potentially effective de-implementation strategy. However, previous studies have shown conflicting results and the mechanism through which active disinvestment may be effective is unclear. This study explored how the active disinvestment initiative regarding subacromial decompression (SAD) surgery for subacromial pain syndrome (SAPS) in the Netherlands influenced clinical decision-making around surgery, including the perspectives of orthopedic surgeonsand hospital sales managers.Methods We performed 20 semi-structured interviews from November 2020 to October 2021 with ten hospital sales managers and ten orthopedic surgeons from twelve hospitals across the Netherlands as relevant stakeholders in the active disinvestment process. The interviews were video-recorded and transcribed verbatim. Inductive thematic analysis was used to analyse interview transcripts independently by two authors and discrepancies were resolved through discussion.Results Two overarching themes were identified that negatively influenced the effect of the active disinvestment initiative for SAPS. The first theme was that the active disinvestment represented a “Too small piece of the pie” indicating little financial consequences for the hospital as it was merely used in negotiations with healthcare insurers to reduce costs, required a disproportionate amount of effort from hospital staff given the small saving-potential, and was not clearly defined nor enforced in the overall healthcare insurer agreements. The second theme was “They [healthcare insurer] got it wrong,” as the evidence and guidelines had been incorrectly interpreted, the active disinvestment was at odds with clinician experiences and beliefs and was perceived as a reduction in their professional autonomy.Conclusion The two overarching themes and their underlying factors highlight the complexity for active disinvestment initiatives to be effective. Future de-implementation initiatives including active disinvestment should engage relevant stakeholders at an early stage to incorporate their different perspectives, gain support and increase the probability of success.

Based on a summary of interviews with 18 experts, Verkerk et al defined the seven key factors that promoted lowvalue care, which included system, social, and knowledge factors. During the ongoing coronavirus disease 2019 (COVID-19) pandemic, these key factors have been influential due to the uncertainty of the disease at the beginning of the pandemic. Globally, several measures have been implemented to reduce low-value care practices and promote high-value care for COVID-19 patients. From huge multicenter, non-industry sponsored or multiplatform trials, to the use of social networks sites is an indispensable and effective way to disseminate medical information. Thanks to these measures, we have transformed a scenario of ignorance into an evidence-based medical scenario in less than a year. Verkerk and colleagues’ proposed key factors are an excellent framework for characterizing and highlighting the lessons that can be learnt from how we have fought against the pandemic and low-value practices.

Background Around the world, policies and interventions are used to encourage clinicians to reduce low- value care. In order to facilitate this, we need a better understanding of the factors that lead to low-value care. We aimed to identify the key factors affecting low-value care on a national level. In addition, we highlight differences and similarities in three countries. Methods We performed 18 semi-structured interviews with experts on low-value care from three countries that are actively reducing low-value care: the United States, Canada, and the Netherlands. We interviewed 5 experts from Canada, 6 from the United States, and 7 from the Netherlands. Eight were organizational leaders or policy-makers, 6 as low-value care researchers or project leaders, and 4 were both. The transcribed interviews were analyzed using inductive thematic analysis. Results The key factors that promote low-value care are the payment system, the pharmaceutical and medical device industry, fear of malpractice litigation, biased evidence and knowledge, medical education, and a ‘more is better’ culture. These factors are seen as the most important in the United States, Canada and the Netherlands, although there are several differences between these countries in their payment structure, and industry and malpractice policy.Conclusions Policy-makers and researchers that aim to reduce low-value care have experienced that clinicians face a mix of interdependent factors regarding the healthcare system and culture that lead them to provide low-value care. Better awareness and understanding of these factors can help policy-makers to facilitate clinicians and medical centers to deliver high-value care.

Verkerk and colleagues explored the key drivers of low-value care from the perspective of 18 policy-makers and researchers who had led and evaluated at least one initiative to reduce low-value care or had been responsible for reducing low-value care in an organisation. They identified several drivers of low-value care presented in the 2017 Lancet Right Care Series (eg, fee for service payment systems, the pharmaceutical and medical device industry, fear of malpractice litigation, issues with research conduct and reporting, a culture of ‘more is better’ and ‘new technology is better’) but did not discuss some other important ones. In this commentary, we aim to extend the work of Verkerk and colleagues and provide some additional perspectives on the drivers of low-value care within the following categories: Economic incentives; Money, finance, and organisation; Knowledge beliefs, assumptions, bias and uncertainty; and Power and human relationships.

Interest has increased in the topic of de-implementation, ie, reducing so-called low-value care (LVC). The article “Key Factors That Promote Low-Value Care: Views From Experts From the United States, Canada, and the Netherlands” by Verkerk and colleagues identifies national-level factors affecting LVC use in those three countries. This commentary raises three critical points regarding the study. First, the study does not clearly define the national level. Secondly, national-level factors might not be relevant for all types of LVCs and thirdly, the study’s rather limited sample makes it difficult to draw firm conclusions. We also include some critical comments related to some of the study’s findings in relation to results of our recently published scoping review of the international literature on de-implementation and use of LVC and an interview study with primary care physicians on LVC use. Finally, we provide some suggestions for further research that we believe is needed to improve understanding of LVC use and facilitate its de-implementation.

Low-value care is increasingly recognized as a global problem that places strain on healthcare systems and has no quick fix. Verkerk et al have identified key factors promoting low-value care on a national level, proposed strategies to address these and create a healthcare system facilitating delivery of high-value care. In this commentary, we reflect on the results of Verkerk et al and argue that uncertainty has a crucial role when it comes to reducing low-value care. This uncertainty is reflected in lack of a shared view between stakeholders, with clear criteria and thresholds on what constitutes low-value care, and as cross-cutting theme related to the key factors identified. We suggest to work on such a shared view of low-value care and – different from implementation efforts – to explicitly address uncertainty and its driving cognitive biases grounded in human decision-making psychology, to reduce low-value care.

Low-value care drivers and interventions are often focused on a microsystem (eg, clinic or inpatient ward) or within a health system. Identification of national drivers such as payment structure and medical culture of overuse can help identify regional approaches to reducing low-value care. However, these approaches in isolation are insufficient and require additional strategies. These can include policy and payment changes and adopting shared decision-making (SDM). SDM has the potential to move medical culture away from the ‘more is better’ paternalistic and physician-centric culture to one that actively engages patients as full partners in managing their care.

Low-value care contributes to poor quality of care and wasteful spending in healthcare systems. In Verkerk and colleagues’ recent qualitative study, interviews with low-value care experts from Canada, the United States, and the Netherlands identified a broad range of nationally relevant social, system, and knowledge factors that promote ongoing use of low-value care. These factors highlight the complexity of the problem that is persistent use of low-value care and how it is heavily influenced by public and medical culture as well as healthcare system features. This commentary discusses how these findings integrate within current low-value care and de-implementation literature and uses specific low-value care examples to highlight the importance of considering context, culture, and clinical setting when considering how to apply these factors to future de-implementation initiatives.

The current coronavirus disease 2019 (COVID-19) pandemic is testing healthcare systems like never before and all efforts are now being put into controlling the COVID-19 crisis. We witness increasing morbidity, delivery systems that sometimes are on the brink of collapse, and some shameless rent seeking. However, besides all the challenges, there are also possibilities that are opening up. In this perspective, we focus on lessons from COVID-19 to increase the sustainability of health systems. If we catch the opportunities, the crisis might very well be a policy window for positive reforms. We describe the positive opportunities that the COVID-19 crisis has opened to reduce the sources of waste for our health systems: failures of care delivery, failures of care coordination, overtreatment or low-value care, administrative complexity, pricing failures and fraud and abuse. We argue that current events can canalize some very needy reforms to make our systems more sustainable. As always, political policy windows are temporarily open, and so swift action is needed, otherwise the opportunity will pass and the vested interests will come back to pursue their own agendas. Professionals can play a key role in this as well.

Background: Several initiatives have been developed to target low-value care (ie, waste) in decision-making with varying success. As such, decision-making is a complex process and context's influence on decisions concerning low-value care is limitedly explored. Hence, a more detailed understanding of residents' decision-making is needed to reduce future low-value care. This study explores which contextual factors residents experience to influence their decision-making concerning low-value care., Methods: We employed nominal group technique (NGT) to select four low-value care vignettes. Prompted by these vignettes, we conducted individual interviews with residents. We analyzed the qualitative data thematically using an inductive-deductive approach, guided by Bronfenbrenner's social-ecological framework. This framework provided guidance to "context" in terms of sociopolitical, environmental, organizational, interpersonal, and individual levels., Results: In 2022, we interviewed 19 residents from a Dutch university medical center. We identified 33 contextual factors influencing residents' decision-making, either encouraging or discouraging low-value care. The contextual factors resided in the following levels with corresponding categories : (1) environmental and sociopolitical: society, professional medical association, and governance ; (2) organizational: facility characteristics, social infrastructure, and work infrastructure ; (3) interpersonal: resident-patient, resident-supervising physician, and resident-others ; and (4) individual: personal attributes and work structure ., Conclusion: This paper describes 33 contextual factors influencing residents' decision-making concerning low-value care. Residents are particularly influenced by factors related to interactions with patients and supervisors. Furthermore, organizational factors and the broader environment set margins within which residents make decisions. While acknowledging that a multi(faceted)-intervention approach targeting all contextual factors to discourage low-value care delivery may be warranted, improving communication skills in the resident-patient dynamics to recognize and explain low-value care seems a particular point of interest over which residents can exercise an influence themselves., (© 2024 The Author(s); Published by Kerman University of Medical Sciences This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.)

Background: Low-value care (LVC) is a critical issue in terms of patient safety and fiscal policy; however, little has been known in Asia. For the purpose of better understanding the extent of LVC on a national level, the utilization, costs, and associated characteristics of selected international recommendations were assessed in this study., Methods: This retrospective cohort study used the National Health Insurance (NHI) claims data during 2013-2017 to evaluate the LVC utilization. Adult beneficiaries who enrolled in the NHI program and received at least one of the low-value services in hospitals were included. We measured seven procedures derived from the international recommendations at the hospital level, and a composite measure was created by summing the total utilization of selected services to determine the overall prevalence and corresponding cost. The generalized estimating equation (GEE) model was adopted to estimate the association., Results: A total of 1 970 496 episodes of LVC was identified among 1 218 146 beneficiary-year observations and 2054 hospital-year observations. Overall, the utilization rate of the composite measure increased from 150.70 to 186.23 episodes per 10 000 beneficiaries with the growth in cost from US$ 5.40 to US$ 6.90 million. LVC utilization was proportional to the volume of outpatient visits and length of stay. Also, hospitals with a large volume of outpatient visits (adjusted odds ratio [aOR]: 95% CI, 2.10: 1.26 to 3.49 for Q2-Q3, 2.88: 1.45 to 5.75 for ≥Q3) and a higher proportion of older patients (aOR: 95% CI, 1.06: 1.02 to 1.11) were more likely to have high costs., Conclusion: The utilization and corresponding cost of LVC appeared to increase annually despite the relatively lower prevalence compared to other countries. Multicomponent interventions such as recommendations, de-implementation policies and payment reforms are considered effective ways to reduce LVC. Repeated measurements would be needed to evaluate the effectiveness of interventions., (© 2024 The Author(s); Published by Kerman University of Medical Sciences This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.)

Background: Withdrawal of reimbursement for low-value care through a policy change, ie, active disinvestment, is considered a potentially effective de-implementation strategy. However, previous studies have shown conflicting results and the mechanism through which active disinvestment may be effective is unclear. This study explored how the active disinvestment initiative regarding subacromial decompression (SAD) surgery for subacromial pain syndrome (SAPS) in the Netherlands influenced clinical decision-making around surgery, including the perspectives of orthopedic surgeons and hospital sales managers., Methods: We performed 20 semi-structured interviews from November 2020 to October 2021 with ten hospital sales managers and ten orthopedic surgeons from twelve hospitals across the Netherlands as relevant stakeholders in the active disinvestment process. The interviews were video-recorded and transcribed verbatim. Inductive thematic analysis was used to analyse interview transcripts independently by two authors and discrepancies were resolved through discussion., Results: Two overarching themes were identified that negatively influenced the effect of the active disinvestment initiative for SAPS. The first theme was that the active disinvestment represented a "Too small piece of the pie" indicating little financial consequences for the hospital as it was merely used in negotiations with healthcare insurers to reduce costs, required a disproportionate amount of effort from hospital staff given the small saving-potential, and was not clearly defined nor enforced in the overall healthcare insurer agreements. The second theme was "They [healthcare insurer] got it wrong," as the evidence and guidelines had been incorrectly interpreted, the active disinvestment was at odds with clinician experiences and beliefs and was perceived as a reduction in their professional autonomy., Conclusion: The two overarching themes and their underlying factors highlight the complexity for active disinvestment initiatives to be effective. Future de-implementation initiatives including active disinvestment should engage relevant stakeholders at an early stage to incorporate their different perspectives, gain support and increase the probability of success., (© 2023 The Author(s); Published by Kerman University of Medical Sciences This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.)

Interest has increased in the topic of de-implementation, ie, reducing so-called low-value care (LVC). The article "Key Factors That Promote Low-Value Care: Views From Experts From the United States, Canada, and the Netherlands" by Verkerk and colleagues identifies national-level factors affecting LVC use in those three countries. This commentary raises three critical points regarding the study. First, the study does not clearly define the national level. Secondly, national-level factors might not be relevant for all types of LVCs and thirdly, the study's rather limited sample makes it difficult to draw firm conclusions. We also include some critical comments related to some of the study's findings in relation to results of our recently published scoping review of the international literature on de-implementation and use of LVC and an interview study with primary care physicians on LVC use. Finally, we provide some suggestions for further research that we believe is needed to improve understanding of LVC use and facilitate its de-implementation., (© 2022 The Author(s); Published by Kerman University of Medical Sciences This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.)

Based on a summary of interviews with 18 experts, Verkerk et al defined the seven key factors that promoted low-value care, which included system, social, and knowledge factors. During the ongoing coronavirus disease 2019 (COVID-19) pandemic, these key factors have been influential due to the uncertainty of the disease at the beginning of the pandemic. Globally, several measures have been implemented to reduce low-value care practices and promote high-value care for COVID-19 patients. From huge multicenter, non-industry sponsored or multiplatform trials, to the use of social networks sites is an indispensable and effective way to disseminate medical information. Thanks to these measures, we have transformed a scenario of ignorance into an evidence-based medical scenario in less than a year. Verkerk and colleagues' proposed key factors are an excellent framework for characterizing and highlighting the lessons that can be learnt from how we have fought against the pandemic and low-value practices., (© 2022 The Author(s); Published by Kerman University of Medical Sciences This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.)

Low-value care drivers and interventions are often focused on a microsystem (eg, clinic or inpatient ward) or within a health system. Identification of national drivers such as payment structure and medical culture of overuse can help identify regional approaches to reducing low-value care. However, these approaches in isolation are insufficient and require additional strategies. These can include policy and payment changes and adopting shared decision-making (SDM). SDM has the potential to move medical culture away from the 'more is better' paternalistic and physician-centric culture to one that actively engages patients as full partners in managing their care., (© 2022 The Author(s); Published by Kerman University of Medical Sciences This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.)

Low-value care is increasingly recognized as a global problem that places strain on healthcare systems and has no quick fix. Verkerk et al have identified key factors promoting low-value care on a national level, proposed strategies to address these and create a healthcare system facilitating delivery of high-value care. In this commentary, we reflect on the results of Verkerk et al and argue that uncertainty has a crucial role when it comes to reducing low-value care. This uncertainty is reflected in lack of a shared view between stakeholders, with clear criteria and thresholds on what constitutes low-value care, and as cross-cutting theme related to the key factors identified. We suggest to work on such a shared view of low-value care and - different from implementation efforts - to explicitly address uncertainty and its driving cognitive biases grounded in human decision-making psychology, to reduce low-value care., (© 2022 The Author(s); Published by Kerman University of Medical Sciences This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.)

Low-value care contributes to poor quality of care and wasteful spending in healthcare systems. In Verkerk and colleagues' recent qualitative study, interviews with low-value care experts from Canada, the United States, and the Netherlands identified a broad range of nationally relevant social, system, and knowledge factors that promote ongoing use of low-value care. These factors highlight the complexity of the problem that is persistent use of low-value care and how it is heavily influenced by public and medical culture as well as healthcare system features. This commentary discusses how these findings integrate within current low-value care and de-implementation literature and uses specific low-value care examples to highlight the importance of considering context, culture, and clinical setting when considering how to apply these factors to future de-implementation initiatives., (© 2022 The Author(s); Published by Kerman University of Medical Sciences This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.)

Background: Around the world, policies and interventions are used to encourage clinicians to reduce low-value care. In order to facilitate this, we need a better understanding of the factors that lead to low-value care. We aimed to identify the key factors affecting low-value care on a national level. In addition, we highlight differences and similarities in three countries., Methods: We performed 18 semi-structured interviews with experts on low-value care from three countries that are actively reducing low-value care: the United States, Canada, and the Netherlands. We interviewed 5 experts from Canada, 6 from the United States, and 7 from the Netherlands. Eight were organizational leaders or policy-makers, 6 as low-value care researchers or project leaders, and 4 were both. The transcribed interviews were analyzed using inductive thematic analysis., Results: The key factors that promote low-value care are the payment system, the pharmaceutical and medical device industry, fear of malpractice litigation, biased evidence and knowledge, medical education, and a 'more is better' culture. These factors are seen as the most important in the United States, Canada and the Netherlands, although there are several differences between these countries in their payment structure, and industry and malpractice policy., Conclusion: Policy-makers and researchers that aim to reduce low-value care have experienced that clinicians face a mix of interdependent factors regarding the healthcare system and culture that lead them to provide low-value care. Better awareness and understanding of these factors can help policy-makers to facilitate clinicians and medical centers to deliver high-value care., (© 2022 The Author(s); Published by Kerman University of Medical Sciences This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.)

Verkerk and colleagues explored the key drivers of low-value care from the perspective of 18 policy-makers and researchers who had led and evaluated at least one initiative to reduce low-value care or had been responsible for reducing low-value care in an organisation. They identified several drivers of low-value care presented in the 2017 Lancet Right Care Series (eg, fee for service payment systems, the pharmaceutical and medical device industry, fear of malpractice litigation, issues with research conduct and reporting, a culture of 'more is better' and 'new technology is better') but did not discuss some other important ones. In this commentary, we aim to extend the work of Verkerk and colleagues and provide some additional perspectives on the drivers of low-value care within the following categories: Economic incentives; Money, finance, and organisation; Knowledge beliefs, assumptions, bias and uncertainty; and Power and human relationships ., (© 2022 The Author(s); Published by Kerman University of Medical Sciences This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.)

The current coronavirus disease 2019 (COVID-19) pandemic is testing healthcare systems like never before and all efforts are now being put into controlling the COVID-19 crisis. We witness increasing morbidity, delivery systems that sometimes are on the brink of collapse, and some shameless rent seeking. However, besides all the challenges, there are also possibilities that are opening up. In this perspective, we focus on lessons from COVID-19 to increase the sustainability of health systems. If we catch the opportunities, the crisis might very well be a policy window for positive reforms. We describe the positive opportunities that the COVID-19 crisis has opened to reduce the sources of waste for our health systems: failures of care delivery, failures of care coordination, overtreatment or low-value care, administrative complexity, pricing failures and fraud and abuse. We argue that current events can canalize some very needy reforms to make our systems more sustainable. As always, political policy windows are temporarily open, and so swift action is needed, otherwise the opportunity will pass and the vested interests will come back to pursue their own agendas. Professionals can play a key role in this as well., (© 2020 The Author(s); Published by Kerman University of Medical Sciences. This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.)