The quality of care anyone receives in the USA is highly dependent on where they receive care. Prior research has found that on average, risk-adjusted mortality differences between top-decile and bottom-decile hospitals can be over twofold. When looking specifically at patient safety, the difference is over 10-fold between top-decile and bottom-decile hospitals. Even after adjusting for population factors (eg, demographics, lifestyle and socioeconomics), co-morbidities and health system factors, these geographic differences in outcomes persist.1 Anyone entering a hospital should be alarmed by the high variability in the quality and outcome of the care they receive simply based on location.

The variability in care and outcomes is even more concerning for people who have faced,2 and continue to face,3 stigma and discrimination in seeking health care. For sexual and gender minority (SGM) populations, including lesbian, gay, bisexual, transgender and queer (LGBTQ+) people, entering a...

What should we do in order to improve quality and safety in medicines management? How beneficial is it to design the medicines management system—for example, the tasks, tools and physical environment—to support effective working versus making people adapt to the systems in which they find themselves? As Sanders and McCormick1 put the question: is it better (more convenient, more cost-effective, more appealing) to bend metal or to twist arms?

This question arises when considering, among other problems in healthcare delivery, that of confusing look-alike, sound-alike (LASA) medicine names, which persists as a threat to medication safety despite much discussion and examination.2 Various measures have been suggested to minimise the risk of LASA medication errors in the pharmacy setting, including education of pharmacy staff, procedural controls and medicines labelling,3 4 although with no silver bullet identified so far.5 6

Background

Given the emphasis on promoting inclusive policies, we investigated the relationship between US hospitals’ inclusion efforts for lesbian, gay, bisexual, transgender, queer or questioning, and other sexual and gender-diverse (LGBTQ+) populations and patient satisfaction from 2016 to 2023.

Methods

This retrospective longitudinal observational study analysed 6 years of data between 2016 and 2023 from the Healthcare Equality Index (HEI), which measures hospitals’ LGBTQ+ inclusion efforts, and the Hospital Consumer Assessment of Healthcare Providers and Systems, which measures patient satisfaction. Generalised estimating equations (GEE) were used to obtain population-averaged estimates of the association between hospitals’ LGBTQ+ inclusion efforts—assessed by (1) their participation and (2) performance in the HEI (range: 0–100)—and patient satisfaction—measured by (1) patients’ hospital rating (range: 0–100) and (2) willingness to recommend the hospital (range: 0–100). We accounted for hospital characteristics, including medical teaching status, specialised service capability, hospital size, ownership, system membership, region and metropolitan location.

Results

Compared with hospitals that never participated in the HEI, those that occasionally participated reported a 0.33-point higher patient rating (p=0.019, 95% CI 0.05, 0.60) and a 0.49-point higher patient recommendation score (p=0.011, 95% CI 0.11, 0.87). Those who always participated reported a 1.30-point higher rating (p<0.001, 95% CI 0.89, 1.70) and a 1.90-point higher recommendation score (p<0.001, 95% CI 1.36, 2.44). Among hospitals that participated in the HEI, a 10-point increase in the total HEI score was associated with a 0.10-point increase in patient ratings (p=0.031, 95% CI 0.01, 0.20) and a 0.15-point increase in patient recommendations (p=0.023, 95% CI 0.02, 0.28).

Conclusion

Hospitals engaging in LGBTQ+ inclusion efforts are associated with higher patient satisfaction.

Background

Wrong-drug medication errors are common. Regulators screen drug names for confusability, but screening methods lack empirical validation. Previous work showed that psycholinguistic tests on pairs of drug names are associated with real-world error rates in chain pharmacies. However, regulators evaluate individual names not pairs, and individual names can be confused with multiple drugs (eg, hydroxyzine with hydralazine but also hydrocet, thorazine, hydrochlorothiazide). This study examines whether an individual drug name’s performance on psycholinguistic tests correlates with that name’s sum total error rate in the real world.

Methods

Nineteen pharmacists and 18 pharmacy technicians completed memory and perception tests assessing confusability of 77 drug names. Tests involved presenting a drug name to participants in conditions that hindered their ability to see, hear or remember the name. Participants typed the name they perceived and selected that name from a menu of alternatives. Error rates on the tests were assessed in relation to real-world rates, as reported by the patient safety organisation associated with a national pharmacy chain in the USA.

Results

Mean error rate on the psycholinguistic tests was positively correlated with the log-adjusted real-world error rate (r=0.50, p<0.0001). Linear and mixed effects logistic regression analyses indicated that the lab-measured error rates significantly predicted the real-world error rates and vice versa.

Conclusions

Lab-based psycholinguistic tests are associated with real-world drug name confusion error rates. Previous work showed that such tests were associated with error rates of specific look-alike sound-alike pairs, and the current work showed that lab-based error rates are also associated with an individual drug’s overall error rate. Taken together, these studies validate the use of psycholinguistic tests in assessing the confusability of proposed drug names.

Background

Medication errors are the leading cause of preventable harm in healthcare. Despite proliferation of medication-related clinical decision support systems (CDSS), current systems have limitations. We therefore developed an indication-based prescribing tool. This performs dose calculations using an underlying formulary and provides patient-specific dosing recommendations. Objectives were to compare the incidence and types of erroneous medication orders, time to prescribe (TTP) and perceived workload using the NASA Task Load Index (TLX), in simulated prescribing tasks with and without this intervention. We also sought to identify the workflow steps most vulnerable to error and to gain participant feedback.

Methods

A simulated, randomised, cross-over exploratory study was conducted at a London NHS Trust. Participants completed five simulated prescribing tasks with, and five without, the intervention. Data collection methods comprised direct observation of prescribing tasks, self-reported task load and semistructured interviews. A concurrent triangulation design combined quantitative and qualitative data.

Results

24 participants completed a total of 240 medication orders. The intervention was associated with fewer prescribing errors (6.6% of 120 orders) compared with standard practice (28.3% of 120 orders; odds ratio 0.18, p<0.01), a shorter TTP and lower overall NASA-TLX scores (p<0.01). Control arm workflow vulnerabilities included failures in identifying correct doses, applying maximum dose limits and calculating patient-specific dosages. Intervention arm errors primarily stemmed from misidentifying patient-specific information from the medication scenario. Thematic analysis of participant interviews identified six themes: navigating trust and familiarity, addressing challenges and suggestions for improvement, integration of local guidelines and existing CDSS, intervention endorsement, ‘search by indication’ and targeting specific patient and staff groups.

Conclusion

The intervention represents a promising advancement in medication safety, with implications for enhancing patient safety and efficiency. Further real-world evaluation and development of the system to meet the needs of more diverse patient groups, users and healthcare settings is now required.

Trial registration number

NCT05493072.

Background

Individuals with sickle cell disease (SCD) experience poor clinical outcomes while transitioning from paediatric to adult care. Standards for SCD transition are needed. We established a Quality Improvement (QI) Collaborative that aimed to improve the quality of care for all young adults with SCD by establishing a standardised SCD transition process. This study evaluates the implementation of the Six Core Elements (6CE) of Health Care Transition, which was a fundamental component of the cluster-randomised Sickle Cell Trevor Thompson Transition Project (ST3P-UP) study.

Methods

A central QI team trained 14 ST3P-UP study sites on QI methodologies, 6CE and Got Transition’s process measurement tool (PMT). Site-level QI teams included a transition coordinator, clinic physicians/staff, patients/parents with SCD and community representatives. Sites completed the PMT every 6 months for 54 months and monthly audits of 10 randomly-selected charts to verify readiness/self-care assessments and emergency care plans.

Results

Of a possible 100, the aggregate mean (±SD) PMT score for paediatric clinics was 23.9 (±13.8) at baseline, 95.9 (±6.0) at 24 months and 98.9 (±2.1) at 54 months. The aggregate mean PMT score for adult clinics was 15.0 (±13.5) at baseline, 88.4 (±11.8) at 24 months and 95.8 (±6.8) at 54 months. The overall QI Collaborative PMT score improved by 402%. At baseline, readiness/self-care assessments were current for 38% of paediatric and 20% of adult patients; emergency care plans were current for 20% of paediatric and 3% of adult patients. Paediatric clinics had one median readiness assessment shift (76%) and four median emergency care plan shifts (65%, 77%, 79%, 84%). Adult clinics experienced three median self-care assessment shifts (58%, 63%, 70%) and two median emergency care plan shifts (57%, 70%).

Conclusions

The ST3P-UP QI Collaborative successfully embedded the 6CE of Health Care Transition into routine care and increased administration of assessments and emergency care plans for transition-aged patients with SCD.

Background

Pulmonary embolism (PE) is a potentially deadly disease and a diagnostic challenge in emergency departments (EDs). Established strategies exist for risk stratification and test stewardship for CT pulmonary angiography (CTPA). However, implementation of best practices has proven challenging, and rising CTPA utilisation increases costs, radiation exposure and ED crowding. We created a multimodal quality intervention to reduce excess CTPA studies and increase the use of d-dimer assays prior to CTPA. Balance measures included the rate of positive CTPA studies and ED returns within 72 hours of discharge.

Methods

This was an observational, pre–post interventional design at three EDs. The intervention included an institutional PE diagnostic guideline, educational sessions, an electronic clinical decision support tool and monthly feedback to individual providers. Consecutive patient data were analysed 1 year pre and 1 year post an intervention on 21 November 2021. Analyses used Pearson 2, logistic regression generalised linear models and XmR statistical process control (SPC).

Results

The study included 307 441 patient encounters, with 35 066 PE evaluations. CTPA utilisation decreased from 6.0% to 5.1% (p<0.01) of all patient encounters, and d-dimer use preceding CTPA increased from 36.6% to 56.3% (p<0.01). For both primary measures, SPC charts showed statistically significant special cause variation compared with the pre-intervention data. There was no significant change in the rate of positive CTPA studies (9.3% vs 10.4%, p=0.14) or 72-hour ED returns (3.0 vs 3.1%, p=0.6).

Conclusions

A multimodal intervention was associated with reduced CTPA utilisation and increased use of d-dimer as the initial test in PE diagnosis, without any negative associated impact on balance measures. This strategy could be reproduced and implemented at other institutions looking to change practice.

Background

Disparities have been identified in many aspects of the cancer care pathway for people from minority ethnic groups (MEGs). Adherence to systemic anticancer therapies (SACTs) has been shown to impact morbidity and mortality, and therefore, inequitable experiences can have a detrimental effect on outcomes.

Objectives

To identify interventions that focused on improving the experiences and clinical outcomes in people from MEG receiving SACT treatments.

Methods

A scoping review was conducted according to Arksey and O’Malley’s methodological framework to map the available literature. A comprehensive search was performed using three electronic databases (Medline, Embase and CINAHL). Standard scoping review methodology following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines was used. Studies were included that assessed interventions to improve MEG patients’ experience with SACT. Study types included in the review were evaluation studies, randomised/non-randomised controlled trials and all observational studies. Exclusion criteria were applied to studies including opinion pieces, literature and systematic reviews, non-English studies, conference abstracts and studies that were not describing an intervention. Independent duplicate screening, study selection, data extraction and quality assessment were undertaken. Results of the studies were synthesised using a published equity framework.

Results

Searches yielded 1356 articles. Nine studies were included after exclusion criteria were applied. Studies described six digital, two in-person and one hybrid intervention employing different research methodologies, ranging from randomised controlled trials (RCTs), feasibility studies and mixed methods studies. The majority of interventions in this study were delivered remotely, using digital platforms such as websites, recorded educational training materials as well as social media. These interventions were conducted in the USA and primarily targeted patients with early breast cancer from African American backgrounds.

Conclusions

This scoping review showed that there has been a very small number of studies investigating interventions to optimise SACT treatment experiences in people from MEG. We found evidence of interventions incorporating the equity domains that reported improved patient engagement and experience. This new knowledge will help to implement future SACT interventions, addressing health inequities across the cancer continuum.

Handoffs have become integral to almost all aspects of hospital-based care. Realities such as duty hour limitations and shift work mean that patients are cared for by numerous individuals each day in an inpatient unit. Furthermore, the specialisation of modern medicine now means that patients transfer between units and care teams as their healthcare needs evolve. This changing of personnel and patient location necessitates handoffs, where clinicians communicate information about the patient, transferring responsibility for care from one person to another. For example, a patient in the hospital might receive care from two separate physician teams (night and day coverage) and three nursing teams (each working an 8-hour shift). This means their care is passed through at least five handoffs in a 24-hour period, not counting potential handoffs to procedural teams, escalations of care or handoffs for break coverage. The number of handoffs in a day for each patient...

Overuse of medical devices such as urinary and vascular catheters remains a pervasive problem contributing to preventable hospital-associated infections and other complications. There is not much mystery remaining about why this happens and how to address it. Nearly two decades of quality improvement studies show us that standardising the indications for catheter insertion, integrating their reassessment into clinical workflow and empowering nurses all lead to more judicious catheter use.1–3

 Despite this evidence, replicating these interventions across institutions, commonly known as spread, is extremely hard. In some countries, national implementation toolkits were created to support hospitals interested in adopting these strategies, like the Comprehensive Unit-based Safety Programme (CUSP) of the Agency for Healthcare Research and Quality (AHRQ) or Choosing Wisely Canada’s ‘Lose the Tube’.4 5 In the USA, CUSP resulted in reduced urinary catheter use in over 10% of hospitals.

Background

Patient-reported experience measures (PREMs) are valuable tools to evaluate patient-centredness (PC) from the patients’ perspective. Despite their utility, a comprehensive PREM addressing PC has been lacking. To bridge this gap, we developed the preliminary version of the Experienced Patient-Centeredness Questionnaire (EPAT), a disease-generic tool based on the integrative model of PC comprising 16 dimensions. It demonstrated content validity. This study aimed to test its psychometric properties and to develop a final 64-item version (EPAT-64).

Methods

In this cross-sectional study, we included adult patients treated for cardiovascular diseases, cancer, musculoskeletal diseases and mental disorders in inpatient or outpatient settings in Germany. For each dimension of PC, we selected four items based on item characteristics such as item difficulty and corrected item–total correlation. We tested structural validity using confirmatory factor analysis, examined reliability by McDonald’s Omega and tested construct validity by examining correlations with general health status and satisfaction with care.

Results

Analysis of data from 2.024 patients showed excellent acceptance and acceptable item–total correlations for all EPAT-64 items, with few items demonstrating ceiling effects. The confirmatory factor analysis indicated the best fit for a bifactor model, where each item loaded on both a general factor and a dimension-specific factor. Omega showed high reliability for the general factor, while varying for specific dimensions. Construct validity was confirmed by absence of strong correlations with general health status and a strong correlation of the general factor with satisfaction with care.

Conclusions

EPAT-64 demonstrated commendable psychometric properties. This tool allows comprehensive assessment of PC, offering flexibility to users who can measure each dimension with a four-item module or choose modules based on their needs. EPAT-64 serves multiple purposes, including quality improvement and evaluation of interventions aiming to enhance PC. Its versatility empowers users in diverse healthcare settings.

Background

A substantial number of people experiencing self-harm or suicidal ideation present to hospital emergency departments (EDs). In 2014, a National Clinical Programme was introduced in EDs in Ireland to standardise care provision. Internationally, there has been limited research on the factors affecting the implementation of care for people who present with mental health crises in EDs.

Methods

This qualitative study examined factors influencing the implementation of the National Clinical Programme for Self-harm and Suicide-related Ideation in 15 hospitals in Ireland from early (2015–2017) through to later implementation (2019–2022). Semi-structured interviews were conducted with staff involved in programme delivery, with the topic guide and thematic analysis informed by the Consolidated Framework for Implementation Research.

Results

A total of 30 participants completed interviews: nurse specialists (n=16), consultant psychiatrists (n=6), nursing managers (n=2), emergency medicine staff (n=2) and members of the national programme team (n=4). Enablers of implementation included the introduction of national, standardised guidance for EDs; implementation strategies led by the national programme team; and training and support for nurse specialists. The following inner-setting factors were perceived as barriers to implementation in some hospitals: limited access to a designated assessment room, delayed access to clinical input and poor collaboration with ED staff. Overall, these barriers dissipated over time, owing to implementation strategies at national and local levels. The varied availability of aftercare impacted providers’ ability to deliver the programme and the adaptability of programme delivery had a mixed impact across hospitals.

Conclusions

The perceived value of the programme and national leadership helped to advance implementation. Strategies related to ongoing training and education, developing stakeholder interrelationships and evaluation and monitoring have helped address implementation barriers and promote continued sustainment of the programme. Continued efforts are needed to support nurse specialists delivering the programme and foster partnerships with community providers to improve the transition to aftercare.

Objective

To assess the association of county-level bias about black and white people with patient experience, influenza immunisation, and quality of clinical care for black and white older US adults (age 65+ years).

Design

Linear multivariable regression measured the cross-sectional association of county-level estimates of implicit and explicit bias about black and white people with patient experiences, influenza immunisation, and clinical quality-of-care for black and white older US adults.

Participants

We used data from 1.9 million white adults who completed implicit and explicit bias measures during 2003–2018, patient experience and influenza immunisation data from respondents to the 2009–2017 Medicare Consumer Assessment of Healthcare Providers and Systems (MCAHPS) Surveys, and clinical quality-of-care data from patients whose records were included in 2009–2017 Healthcare Effectiveness Data and Information Set (HEDIS) submissions (n=0.8–2.9 million per measure).

Main outcome measures

Three patient experience measures and patient-reported influenza immunisation from the MCAHPS Survey; five HEDIS measures.

Results

In county-level models, higher pro-white implicit bias was associated with lower immunisation rates and worse scores for some patient experience measures for black and white adults as well as larger-magnitude black-white disparities. Higher pro-white implicit bias was associated with worse scores for some HEDIS measures for black and white adults but not with black-white disparities in clinical quality of care. Most significant associations were small in magnitude (effect sizes of 0.2–0.3 or less).

Conclusions

To the extent that county-level pro-white implicit bias is indicative of bias among healthcare providers, there may be a need for interventions designed to prevent such bias from adversely affecting the experiences and preventive care of black patients and the clinical quality of care for all patients.

Background

Handoffs are a weak link in the chain of clinical care of inpatients. Within-unit handoffs are increasing in frequency due to changes in duty hours. There are strong rationales for standardising the reporting of critical information between providers, and such practices have been adopted by other industries.

Objectives

As part of Making Healthcare Safer IV we reviewed the evidence from the last 10 years that the use of structured handoff protocols influences patient safety outcomes within acute care hospital units.

Methods

We searched four databases for systematic reviews and original research studies of any design that assessed structured handoff protocols and reported patient safety outcomes. Screening and eligibility were done in duplicate, while data extraction was done by one reviewer and checked by a second reviewer. The synthesis of results is narrative. Certainty of evidence was based on the Grading of Recommendations Assessment, Development and Evaluation framework as modified for Making Healthcare Safer IV.

Results

We searched for evidence on 12 handoff tools. Two systematic reviews of Situation, Background, Assessment, Recommendation (SBAR) (including 11 and 28 original research studies; 5 and 15 were about the use in handoffs) and two newer original research studies provided low certainty evidence that the SBAR tool improves patient safety outcomes. Ten original research studies (about nine implementations) provided moderate certainty evidence that the I-PASS tool (Illness severity, Patient summary, Action list, Situation awareness, Synthesis to receiver) reduces medical errors and adverse events. No other structured handoff tool was assessed in more than one study or one setting.

Conclusion

The SBAR and I-PASS structured tools for within-unit handoffs probably improve patient safety, with I-PASS having a stronger certainty of evidence. Other published tools lack sufficient evidence to draw conclusions.

PROSPERO registration number

CRD42024576324.

Purpose

This systematic review aims to identify the implementation strategies of financial navigation and systematically synthesise its effects on mitigating financial toxicity among cancer survivors, based on the theoretical framework of implementation science.

Methods

Medline, Web of Science Core Collection, ScienceDirect and ProQuest Health & Medical Collection databases were searched for studies published before 22 August 2023. We sought original research on financial navigation interventions among adult cancer survivors with financial toxicity in healthcare settings. The Revised Cochrane risk-of-bias tool for randomised trials, 2.0 and the Risk Of Bias In Non-randomised Studies of Interventions-I were used to assess the risk of bias in included studies. In addition, the implementation strategies of the included studies were categorised and collated based on Expert Recommendations for Implementing Change, and the Consolidated Framework for Implementation Research was adopted to explain barriers and facilities for implementation.

Results

In total, 6855 records were screened, yielding 14 full-text articles, which were included (3 randomised clinical trials and 11 non-randomised studies). ‘Train and educate stakeholders’ (n=13 (92.9%)) and ‘use evaluative and iterative strategies’ (n=12 (85.7%)) were the most common implementation strategies in financial navigation. The feasibility of financial navigation is relatively high, but generally hindered by the health condition of cancer survivors, low willingness to participate and insufficient number of navigators to cover all participants. After the intervention, three of seven studies reported statistically significant mitigations in patient-reported financial toxicity. In studies reporting statistically significant outcomes, ‘adapt and tailor to the context’ and ‘change infrastructure’ were proposed as key corresponding recommendations.

Conclusions

Financial navigation is a potentially beneficial intervention for lessening the financial toxicity of cancer survivors, but more high-level evidence is needed for further validation. Financial navigation combined with the theoretical framework of implementation science provides a foundation for the future realisation of the leap from knowledge to practice.

PROSPERO registration number

CRD42023469114.

Many successful implementation studies fail to be sustained and spread after the publication. We aimed to spread a successful deimplementation strategy that reduced inappropriate peripheral venous catheter and urinary catheter use and evaluated the spread, adoption and effects of this strategy in clinical practice.

We adapted the original successful study into a more accessible project, creating a toolkit called Better without catheter. We recruited 39 hospitals (more than half of all Dutch hospitals) across the Netherlands, which participated in regular online meetings. After 21 months, we sent an online survey to the project leaders of the participating hospitals to assess progress, barriers and facilitators to adopting the project.

Widespread promotion and targeted emails were key factors in spreading Better without catheter. There was considerable variation in the hospitals’ progress; five had not yet started, six had completed the project and the others were at various stages in between. Major barriers included lack of time and resources, organisational facilities and the composition of local project teams. Key facilitators were organisational support and the involvement of physicians and nurse leaders. Project leaders valued the toolkit, the flexibility to tailor the project and the online meetings.

Overall, the spread and adoption of this deimplementation strategy showed encouraging results, with 39 hospitals joining the network within 2 years. Although reach and engagement were high, the hospitals’ progress in the project was frequently hindered by organisational and management factors. Four elements supported the uptake: widespread promotion, the translation of the original study into an accessible improvement project with practical tools, the flexibility to tailor the approach locally and participation in a peer network.

Prusaczyk B, Burke RE. It’s time for the field of geriatrics to invest in implementation science. BMJ Qual Saf 2023;32:700-703.

In this article, the affiliation ‘Central and North West London NHS foundation Trust’ has been added to Simon Conroy and the funding statement has been updated to acknowledge the funding from the NHS Elect and Central and North West London NHS foundation Trust.

doi: 10.1136/bmjqs-2023-016263corr1

Tackling overuse in healthcare is now more necessary than ever. Movements such as Choosing Wisely and Preventing Overdiagnosis have highlighted that some healthcare services offer no added value and may even cause harm to patients. Estimates of overdiagnosis and overtreatment vary widely between services, providers and regions.1 2 Overuse is a persistent challenge in high-income countries and is increasingly recognised in low-income settings.3 Action is needed to prevent patient harm, reduce resource waste and preserve the limited time of healthcare professionals. In addition, since healthcare services have a significant environmental impact, minimising overuse can contribute to achieving climate goals.

De-implementation science

To accelerate the reduction of overuse, robust de-implementation science is essential.4 This field studies the drivers, strategies and processes involved in reducing or eliminating ineffective, unnecessary or harmful healthcare practices, and in replacing them with evidence-based, high-value alternatives. Rigorous...

Sepsis remains a leading cause of morbidity and mortality worldwide.1 The use of artificial intelligence (AI), and particularly machine-learning (ML) approaches, to predict which patients are at risk for sepsis in the hospital may improve patient-centred outcomes through early recognition and timely antibiotics. Yet, despite major interest in the use of ML applications in sepsis care, there are only a handful of successful examples of model implementation that save lives through early detection.2 3 The high cost and extensive system architecture required to test and implement novel ML applications have limited many institutions’ abilities to bring these models to the bedside. Unfortunately, this has resulted in a preponderance of studies on model development rather than implementation and reliance on proprietary models disseminated to health systems without validation or testing. One well-known sepsis predictive model developed by an electronic health record vendor (Epic Systems,...

Background

Low-value care (LVC) describes practices that persist in healthcare, despite being ineffective, inefficient or causing harm. Several determinants for the provision of LVC have been identified, but understanding how these factors influence professionals’ decisions, individually and jointly, is a necessary next step to guide deimplementation.

Methods

A factorial survey experiment was employed using vignettes that presented hypothetical medical scenarios among 593 Swedish primary care physicians. Each vignette varied systematically by factors such as patient age, patient request for the LVC, physician’s perception of this practice, practice cost to the primary care centre and time taken to deliver it. For each scenario, we measured the reported likelihood of providing the LVC. We collected information on the physician’s worry about missing a serious illness.

Results

Patient requests and physicians’ positive perceptions of the practice were the factors that increased the reported likelihood of providing LVC the most (by 14 and 13 percentage points (pp), respectively). When the LVC was low in cost or not time-consuming, patient requests further boosted the likelihood of provision by 29 and 18 pp. In contrast, credible evidence against the LVC reduced the role of patient requests by 11 pp. Physicians’ fear of missing a serious illness was linked with higher reported probability of providing LVC, and the credibility of the evidence against the LVC reduced the role of this concern.

Conclusions

The findings highlight that patient requests enhance the role of many determinants, while the credibility of evidence diminishes the impact of others. Overall, these findings point to the relevance of increased clinician knowledge about LVC, tools for patient communication and the use of decision support tools to reduce the uncertainty in decision-making.