VA Clinicians' Perspectives on Low-Value Health Service Use in the Veterans Health Administration: A Qualitative Study.

Abstract

Background: Low-value health services adversely affect outcomes and unnecessarily increase the cost of care. Approximately 10% of Veterans receive at least one of 29 low-value services delivered or paid for by the Veterans Health Administration (VA) annually. However, determinants of and potential solutions to reduce low-value service delivery are poorly understood.

Objective: To characterize the drivers of and approaches to reduce low-value service delivery across VA Medical Centers (VAMCs) from the perspective of VA clinicians.

Design: Qualitative study using semi-structured interviews conducted from October 2022 to November 2023.

Participants: 65 VA clinicians, including 32 generalists and 33 medical and surgical specialists, at 46 VAMCs.

Approach: We used deductive analysis based on a priori categories and definitions structured by the Theoretical Domains Framework to identify predominant themes related to drivers of low-value service delivery. We used inductive analysis to identify clinician-suggested approaches to reduce low-value services.

Key results: We identified three overarching domains as drivers of low-value service delivery at VA: 1) environmental context and resources; 2) social influence; and 3) belief about consequences. Regarding key subthemes, social pressure from Veterans emerged among generalists and specialists. Generalists were more likely to identify referral parameters or requirements compared to specialists, while specialists were more like to identify negative consequences compared to generalists. We identified four overarching domains as approaches to reduce low-value service delivery at VA, which were consistently identified by both generalists and specialists: 1) improving quality and access to VA health care; 2) dissemination of best practices; 3) optimizing use of the electronic health record; and 4) instilling an organizational culture on value.

Conclusions: We identified the most salient drivers of and approaches to reduce low-value services from the perspective of VA clinicians. These findings may inform the design of future de-implementation interventions and policy to reduce VA-delivered low-value services.