Skip to main content

Table 5 Implementation barriers

From: Addressing overuse of health services in health systems: a critical interpretive synthesis

Categories

Barriers

Explanation

Patient/public level

• Online information

• Patients have access to websites and advertisements of varying quality that may lead them to asking for tests or procedures that they do not need

• Resistance: not consulted early enough

• The shared decision-making process needs to be perceived as legitimate and transparent, especially by the public; however, the level of public involvement may vary, depending on the nature of the decision and the personal preferences of members of the public

• Resistance: may not want services rationed

• The natural inclination of people (patients and clinicians alike) is to perceive a greater disadvantage from the withdrawal of an already existing service as opposed to the denial of a new service of similar value; additionally, patients may feel entitled to services that have been available in the past

• Funded by interest groups

• Some patient groups may be funded by the manufacturers of drugs and technologies, and these groups could influence stakeholder- and consumer engagement processes to identify overused health services

• Lack of information

• Some patients may not feel sufficiently informed to properly contribute to the shared decision-making process

Clinician

• Obtaining agreement from providers regarding what is unnecessary

• Some providers may not be aware of or agree with the services that have been identified as overused and they may view the service as necessary, which could be the result of many reasons such as publication bias (i.e. where they read mostly what should be done and not what should not) or industry pressure where more is viewed as better

• Providers may resist the encroachment on autonomy and income

• Providers, even if they do understand about overuse and its implications, may still be reluctant to accept limitations on their service use as this goes against their financial incentives, as well as against patient choice and provider autonomy to decide which treatment options are best

• Providers may view this as a passing fad

• Providers may perceive these initiatives as just another passing fad, and therefore may not invest energy in them

• May focus on low hanging fruit or other specialties

• Providers may not want to withdraw funds from services within their specialty, and therefore will only focus on low-hanging fruit or shift responsibility to other specialties and their overuse

Organisation

• May have competing interests

• Some organisations may have competing interests and priorities and therefore may resist collaborating with such an initiative

• May need extra resources

• Organisations may view such an initiative as requiring extra organisational resources (e.g. shared decision-making requires more time with patients and hence more resources)

• Fatigue due to too many initiatives

• Some organisations may be experiencing fatigue (e.g. some organisations and their management may be tired of new ideas so there may be resistance to implementing another new initiative)

• Lack of infrastructure

• Some organisations may not have the infrastructure to implement the necessary changes

Health system

• Lack of awareness

• Some health system leaders may not be aware of the issues and the potential negative outcomes of the overuse of health services

• Lack of political will

• Some health system leaders may lack the political will to address the overuse of health services

• Coordination between levels in the health systems

• Building consensus between stakeholders and different levels of government will be challenging, which will make coordination at a national level challenging

Lack of evaluation/evidence

• Lack of evidence that certain tests/treatments are being overused

• There is a lack of evidence and published literature that clearly demonstrate that existing health services provide little or no benefit, and at times cause harm

• The data to demonstrate that there is overuse does not always exist or is not always easily accessible

• Lack of information that certain organisations or providers are actually overusing the service

• Stronger evidence and access to data is needed to demonstrate overuse across providers, organisations and jurisdictions

• Lack of belief that the current evidence is correct (i.e. when physicians are presented with variations of care, they question the evidence)

• When presented with evidence of overuse, many providers challenge the evidence base and are resistant to accept the results