Study 5: Unravelling Low-Value Care Decision-Making: Residents’ Perspectives on the Influence of Contextual Factors

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. Relevant documents The interview transcripts can be viewed in ‘InterviewsContextualFactors’.