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58 Primary care physicians’ perspectives on low-value care and barriers to de-implementation: survey in six high-income countries
  1. Aleksi Raudasoja1,2,
  2. Kari Tikkinen2,
  3. Jorma Komulainen1,
  4. Raija Sipilä1,
  5. Ulrike Spary-Kainz3,
  6. Muna Paier-Abuzahra3,
  7. Muaad Hussien4,
  8. Emir Ouahrani5,
  9. Paolo Francesconi6,
  10. Benedetta Bellini6,
  11. Yuki Kaji7,
  12. Shunzo Koizumi8,
  13. Eliana Ben-Sheleg9,
  14. Moriah Ellen10,
  15. Eleni Karlafti11
  1. 1Medical Society Duodecim, Helsinki, Finland
  2. 2University of Helsinki, Helsinki, Finland
  3. 3Institute of General Practice and Evidence-Based Health Services Research, Medical University of Graz, Graz, Austria
  4. 4Department of Medicine, Mälarsjukhuset Hospital, Eskilstuna, Sweden
  5. 5Karolinska University Hospital, Department of geriatrics, Stockholm, Sweden
  6. 6Regional Health Agency, Florence, Italy
  7. 7Department of General Medicine, International University of Health and Welfare Narita Hospital, Narita, Japan
  8. 8Shichijo Clinic, Kyoto, Japan
  9. 9Department of Epidemiology, Biostatistics and Community Health Sciences, Ben-Gurion University, Beer-sheva, Israel
  10. 10Department of Health Policy and Management, Guilford Glazer Faculty of Business and Management, Ben-Gurion University of the Negev, Beer-sheva, Israel
  11. 11EFIM, Athens, Greece


Objectives Barriers to de-implementation have been studied in several studies, but it remains uncertain, which barriers are the most important in general. Our aim was to identify the most important barriers to de-implementation and map potential differences in attitudes towards low-value care use in primary care in high-income countries.

Methods The online survey was distributed to primary care physicians in six high-income countries by email. Responders were eligible if they had worked in primary care in the previous 24 months. Between May and June 2022, we sent a heads-up, an invitation, and two reminder emails. Local medical associations provided the email lists for distribution or distributed the survey themselves. The survey included five sections: i) background information, ii) familiarity with Choosing wisely recommendations, iii) attitudes towards overdiagnosis and overtreatment, iv) barriers to de-implementation, and v) interventions and possible facilitators for de-implementation. Sections ii-iv included categorized questions and section v open-ended questions. We used descriptive statistics to present the survey responses.

Results We sent the survey to 16,935 primary care physicians and 1,731 answered (response rate 10,2%). Of 1505 eligible responders, 26% had never heard of Choosing Wisely recommendations, 20% had heard of them, 32% had read a few, and 21.0% had read many of them. Almost all responders (98%) perceived overdiagnosis and overtreatment as either a similar or bigger problem for their healthcare system compared to their own practice. The five most important barriers were patient expectations (85% answered either moderate or major importance), patient’s requests for treatments and tests (83%), fear of medical error (81%), workload and lack of time (81%), and fear of underdiagnosis or undertreatment (79%). Higher attitudes correlated with higher age and Choosing Wisely familiarity. Higher perceptions of barriers were correlated with higher attitudes and lower age. Both attitudes and perceptions of barriers were statistically different between countries.

Conclusions Primary care physicians see that others rather than themselves have more often a problem with the use of low-value care. Lack of time, fear of medical error, and patient pressures are common barriers to de-implementation in high-income countries and should be acknowledged when planning future healthcare. As a wide range of barriers can deter the de-implementation at the same time and the importance of barriers might differ between the contexts, it is of utmost importance to understand the local barriers in planning de-implementation strategies.

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