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

Document Type : Original Article


1 Academy of Postgraduate Medical Education, Maastricht University Medical Centre, Maastricht, The Netherlands

2 School of Health Professions Education, Maastricht University, Maastricht, The Netherlands

3 Department of Neurosurgery, Maastricht University Medical Centre, Maastricht, The Netherlands

4 Faculty of Health, Medicine, and Life Sciences, Maastricht University, Maastricht, The Netherlands

5 Department of Intensive Care Medicine, Maastricht University Medical Centre, Maastricht, The Netherlands

6 Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Centre, Maastricht, The Netherlands


Several initiatives have been developed to target low-value care (ie, waste) in decision-making with varying success. As such, decision-making is a complex process and context’s influence on decisions concerning lowvalue 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.
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.
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.
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. 


  • Receive Date: 22 December 2022
  • Revise Date: 06 January 2024
  • Accept Date: 10 March 2024
  • First Publish Date: 11 March 2024