Unravelling Low-Value Care Decision-Making: Residents' Perspectives on the Influence of Contextual Factors.

BACKGROUND: Several initiatives have been developed to target low-value care (i.e. 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 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.

Evaluation of a Four-Week Online Resilience Training Program for Multiple Sclerosis Patients.

The diagnosis of a chronic disease, such as multiple sclerosis, has both psychological and physical effects. Living with the disease and its uncertain consequences requires a great deal of psychological resilience in order to employ more comprehensive coping strategies in stressful situations. This study investigated the effect of a four-week online self-directed resilience training program on the perception of psychological resilience among multiple sclerosis patients. A total of 94 MS patients were recruited for a randomised controlled trial. The experimental group underwent a 28-day online self-directed training program consisting of daily exercises aimed at strengthening a resilient mindset. Psychological resilience was measured through self-assessment immediately before, immediately after, and three months after the training. A repeated measures ANOVA revealed a statistically significant improvement in the perception of four factors related to stress: perceived worries, tension, joy, and demands. Two resilience coping strategies were measured, of which one, a resilient orientation, improved significantly in the short and long term. The study suggests that online self-directed resilience training might provide an easily accessible, low-cost option for patients with MS to improve their psychological resilience. This is a pilot study to assess the general applicability to people with MS. Future studies should examine the transferability of results in relation to disease stage and co-morbidities.

A Social Network Analysis of Influences on Residents' Value-Based Decisions.

PURPOSE: To ensure a value-based health care system, it is becoming increasingly important that residents are trained in making value-based decisions. This study explored the social network influencing residents' value-based decisions. METHOD: To explore the social network influencing residents' value-based decisions, the authors used a semistructured individual and mini-group interviewing approach and participatory visual mapping. In total, 17 residents across 13 different specialties were interviewed from the southeastern postgraduate medical education and training region of the Netherlands, May-November 2021. Two researchers independently coded the transcribed data using an integrated inductive thematic approach. Subsequently, social network analysis was used to visualize the results. RESULTS: Residents indicated that their value-based decisions were influenced by direct actors who influenced decisions related to patients and indirect actors who shaped decisions related to patients without directly modifying them. Different interaction-aspects (i.e., personal, situational, and institutional) further affected residents' ability to make value-based decisions. Thus, residents' value-based decisions were a product of the interplay between various interactions with actors and different interaction-aspects. Residents defined value-based decisions differently, even within an interview. CONCLUSIONS: These results suggest residents' value-based decisions are influenced by a multitude of actors, including hierarchically superior colleagues who can directly alter decisions and patients (and their families) and nurses with whom residents consider it important to maintain good relationships. In addition, more experienced actors, mainly from the medical and nursing profession, contribute most to learning. Furthermore, residents' value-based decisions are deeply underpinned by the hidden curriculum. However, many senior physicians may not have received sufficient training in the concept of value-based health care. Consequently, an approach of formally educating residents in value-based health care will likely have limited effects unless social influences in day-to-day clinical settings reinforce its importance.

Endovascular treatment and neurosurgical clipping in subarachnoid hemorrhage: a systematic review of economic evaluations.

INTRODUCTION: There are two treatment modalities for aneurysmal subarachnoid hemorrhage: endovascular treatment (EVT) and neurosurgical clipping. Results of economic evaluations are needed to gain insight into the relationship between clinical effectiveness and costs of these treatment modalities. This important information can inform both clinical decision-making processes and policymakers in facilitating Value-Based Healthcare. EVIDENCE ACQUISITION: Databases (PubMed, Embase, Cochrane Library, the Centre for Reviews and Dissemination, EBSCO, and Web of Science) were searched for studies published until October 2020 that had performed economic evaluations in aneurysmal subarachnoid hemorrhage patients by comparing EVT with neurosurgical clipping. The quality of reporting and methodology of these evaluations was assessed using the associated instruments (i.e. CHEERS statement and CHEC-list, respectively). EVIDENCE SYNTHESIS: A total of 6 studies met the inclusion criteria. All included studies reported both effects and costs, however five did not relate effects to costs. Only one study related effects directly to costs, thus conducted a full economic evaluation. The reporting quality scored 81% and the methodological quality scored 30%. CONCLUSIONS: The quality of published cost-effectiveness studies on the treatment of aneurysmal subarachnoid hemorrhage is poor. Six studies reported both outcomes and costs, however only one study performed a full economic evaluation comparing EVT to neurosurgical clipping. Although the reporting quality was sufficient, the methodological quality was poor. Further research that relates health-related quality of life measures to costs of EVT and neurosurgical clipping is required - specifically focusing on both reporting and methodological quality. Different subgroup analyses and modeling could also enhance the findings.

The Effectiveness of a Four-Week Online Mindfulness Training Course on Individual Mindfulness Skills and Personal Perception of Stress in Company Employees Working from Home.

Working from home comes with many benefits. However, employees are often exposed to various stressors when working outside of the traditional workplace environment. The subjective experience of these stressors is related to one's perception of the situation and the perceived resources available. As working from home has become the new normal for many during the COVID-19 pandemic, it is in the interest of companies to provide employees with tools to cope with these stressors. One such tool is online mindfulness training. This study investigates how a four-week online mindfulness training influences an individual's mindfulness skills, subjective perception, and processing of stressors. Forty participants working from home at the time of the study were examined in a pre-test using a pre-post design in which the experimental group participated in a four-week online training course in mindfulness. Since the results showed a significantly reduced subjective perception of stress in the experimental group after mindfulness training, a long-term study was conducted including 40 additional participants. The study revealed a training success of at least three months. It thus introduces new possibilities for effective stress management in all workplace settings.

Positive Health dialogue tool and value-based healthcare: a qualitative exploratory study during residents' outpatient consultations.

OBJECTIVE: To explore how residents experienced the application of the Positive Health dialogue tool (PH-tool) during outpatient consultations and its influence on the delivery of value-based healthcare (VBHC). DESIGN: Qualitative study using non-participant observations of outpatient consultations during which residents used the PH-tool, followed by longitudinal individual, semistructured interviews. To analyse the data from observations and interviews, observational form notes' summarisation and categorisation, and an iterative-inductive thematic approach was used. PARTICIPANTS: Eight residents-five from the ear, nose, and throat-department and three from the gastroenterology-hepatology-department-were selected through convenience sampling, accounting for 79 observations and 79 interviews. RESULTS: Residents had bivalent experiences with using the PH-tool. Residents discussed three main benefits: a gained insight into the individual patient's context and functioning, a changed dynamics in resident-patient communication, and an increased awareness regarding value in terms of patient-related outcomes and healthcare costs. Three barriers became apparent: doubts regarding the PH-tool's relevance and scope, boundaries of superspecialised medical professionals, and a lack of demarcation in clinical practice. CONCLUSION: The PH-tool use can be beneficial for residents during outpatient consultations with new patients and follow-up in cases of multidimensional problems, particularly in cases of chronic conditions and generalist care. In these situations, the tool yielded valuable patient information beyond physical health, helped foster patient engagement, and enabled tailoring the treatment plan to individual patients' needs. On the other hand, the PH-tool was not a good fit for simple problems, clearly demarcated help requests, periodic follow-up consultations, or verbose patients. In addition, it was not suitable for superspecialised care, because it yielded an abundance of general information. For particular patients and problems, using the PH-tool seems a promising strategy to increase VBHC delivery. Nevertheless, further research and detailing is needed to better align the PH-tool's broad intent and clinical practice.