Knowledge, attitude, and practice toward value-based care among Chinese nurse: a cross-sectional study

Abstract

Background

Value-Based Care (VBC) is increasingly recognized as a pivotal approach in healthcare, aiming to improve patient outcomes while optimizing costs. Understanding the knowledge, attitudes, and practices (KAP) of nurses towards VBC is crucial for its successful implementation.

Methods

This study adopts a multi-center, online, cross-sectional design to survey registered nurses across China to evaluate their KAP related to VBC.The survey was disseminated through the platform Wenjuanxing (SoJump) targeting professional nursing groups, utilizing a structured questionnaire on a five-point Likert scale.

Result

The survey received a total of 1,825 valid responses from 82 hospitals across 18 provinces, with the majority coming from female nurses (95.02%), and a significant portion of the nurses having 10–19 years of clinical experience. 41.32% of the participants indicated they were familiar with Value-Based Care (VBC), and 68% expressed a willingness to participate in relevant training. There was a significant difference (p < 0.001) in the reported incidence of low-value services between nurses' self-reports and their reports about colleagues, with a lower incidence reported by nurses themselves. The highest incidence of low-value services reported by nurses themselves was "Unnecessary Lab testing" (6.52%), while the highest incidence reported by nurses about their colleagues was "Insufficient Treatment" (12.75%).

Conclusion

This survey showed that Chinese nurses have a relatively low level of understanding of value-based healthcare, and that low-value medical practices may be prevalent in China.

What is already known

• No studies have investigated the knowledge, attitudes, and practices regarding value-based care among nurses in China.

• A curriculum for value-based healthcare has not yet been implemented in China.

What this paper adds

• This study complements the research on the knowledge, attitudes, and practices regarding value-based care among Chinese nurses.

• This study found that there may be a considerable number of low-value healthcare practices in China, and the incidence of low-value practices reported by nurses themselves is lower than that reported by their colleagues.

Background

In recent years, the concept of value-based care (VBC) has gained significant attention in the global healthcare sector. Value-based healthcare was first proposed by Michael Porter and his colleagues in 2006. It is a model of healthcare management aimed at meeting patient needs and achieving optimal health outcomes through the provision of high-quality and cost-effective healthcare services, while also managing the use of medical resources efficiently [1]. Currently, China began piloting a new payment model in 2019: Disease-Related Groups (DRG) payment, which has evolved into a mainstream payment method. While notable achievements have been made in the implementation of the DRG reforms, some issues have gradually emerged. As DRG is a prepaid medical insurance payment method, hospitals are responsible for covering any medical expenses that exceed the amount allocated for the patient's diagnosis group. Consequently, to maintain profitability and ensure sustainable development, hospitals may reduce necessary services or add unnecessary ones, potentially compromising patient health [2, 3]. Therefore, experts have proposed incorporating the concept of value-based healthcare into the DRG reform, shifting the DRG payment system from one driven by service volume to one driven by value [4]. Nurses, as integral members of healthcare teams, play a crucial role in the successful implementation of VBC [5]. However, there is a lack of research exploring the knowledge, attitudes, and practices (KAP) towards VBC among Chinese nurses.

This study aims to describe the current status of Chinese nurses' knowledge, attitudes, and practices (KAP) towards value-based healthcare, providing evidence for its implementation in China.

Methods

Study design and participants

This study employed a multi-center online cross-sectional survey using a self-administered anonymous questionnaire.

The inclusion criteria for participants included: (a) Age of 20 years or older; and (b) Registered nurses; Intern nurses were excluded.

Data collection

Data were collected through an online survey using the platform Wenjuanxing (SoJump), a widely used online survey tool in China. Participation in the survey was voluntary, and respondents were assured of anonymity and confidentiality. A total of 1,829 nurses participated, resulting in 1,825 valid responses after excluding invalid questionnaires, yielding an effective response rate of 99.78%.

The Medical Ethics Committee of West China Hospital, Sichuan University, approved the research protocol prior to the official commencement of the survey.

Questionnaire

In this study, a structured questionnaire using a Likert five-point scale was used to assess the knowledge, attitudes, and practices of Chinese nurses towards Value-Based Care (VBC). The questionnaire was revised based on four similar surveys that had been previously conducted [6,7,8,9]. With additional modifications made to adapt it to the Chinese context, Prior to the formal survey, a pilot test was conducted with a convenience sample of 5 experts. Their feedback was then incorporated into the final version of the questionnaire.The overall Cronbach's alpha coefficient of the formal questionnaire is 0.934, and the KMO value is 0.936, indicating that the questionnaire has good reliability and validity. (The details of the questionnaire can be found in the appendix.)

Data analysis

Data analysis was conducted using IBM SPSS Statistics version 26. Descriptive statistics, including frequencies and percentages, were used to summarize demographic characteristics and survey responses. A matched-sample t-test was used to explore the differences between self-reported and colleague-reported incidences of low-value practices.

Results

Demographic characteristics of participants

This survey included participants from 82 hospitals across 18 provinces, with a predominant female population (95.02%), focusing on younger and middle-aged groups. Most participants had 10–19 years of clinical experience and held undergraduate degrees. The distribution of participants was nearly equal between northern and southern China. Among the participants, the largest group held primary-level professional titles, and the majority worked in tertiary-level healthcare institutions. Detailed demographic data are summarized in Table 1.

Table 1 Participants’ main characteristics

Knowledge

In the knowledge dimension, self-reported familiarity indicates that participants have a moderate level of understanding of VBC concepts. Specifically, 41.32% of participants reported understanding VBC (Item K1), and 46.61% reported understanding the overall costs incurred by patients during healthcare services (Item K2). The objective accuracy in comprehending the core aspects of VBC is slightly higher, with a 52.60% accuracy rate in understanding value (Item K3) and a 45.04% accuracy rate in understanding the goals of VBC, namely improving healthcare outcomes per unit of cost (Item K4). See Table 2 for details.

Table 2 Comparison of self-reported familiarity rate and objective accuracy in the VBC knowledge assessment

Attitude

In the attitude dimension, the survey results indicate that participants generally hold a positive attitude towards Value-Based Care (VBC), with approval rates exceeding 50% across all dimensions. The three items with the highest approval rates are: "Your attitude about participating in training on reducing low-value services or providing high-value care" (A6, 68%), "In your institution, Value-Based Care is a relevant concept" (A3, 67%), and "Value-Based Care is a relevant concept for the healthcare system" (A2, 66%). The three items with the lowest approval rates are: "Value-Based care will increase costs in administration" (A6, 52%), "Value-Based Care will reduce the range of procedures with low success rates" (A4, 56%), and "You have the confidence to provide high-quality healthcare to your patients" (A8, 60%). For more information, see Fig. 1.

Fig. 1

Self-reported proportion of different attitudes towards value-based care

Practice

In the practical dimension, the study found that there was a significant difference (p < 0.001) between the incidence of low-value practices self-reported by nurses and the incidence of low-value practices they reported among their colleagues. The incidence of low-value practices self-reported by nurses was lower than that reported by their colleagues (Table 3). Among the self-reports of nurses, the three items with the highest incidence of low-value practices were "Unnecessary Lab Testing" (P5, 6.52%), "Refusing to Treat Patients" (P6, 6.25%), and "Breaking Down Hospitalization" (P3, 5.97%).Among the reports of colleagues' low-value practices, the three items with the highest incidence were "Insufficient Treatment" (P1, 12.75%), "Breaking Down Hospitalization" (P3, 12.64%), and "Up Coding" (P2, 12.09%).For more details, see Fig. 2.

Table 3 Matched-sample t-test for low-value service occurrence scores across different report objects

Fig. 2

Incidence rates of low-value behaviors reported by responders among themselves and their colleagues

Discussion

This study describes the current status of Chinese nurses' KAP (knowledge, attitude, and practice) towards value-based healthcare(VBC).In the ‘knowledge’ section, only half of the research subjects are aware of VBC, but they have a correct understanding of its concept. Most of them believe that the level of value is not directly related to the hospital's income level, and that low value healthcare does not mean cheap healthcare. Because the value itself refers to the improvement of patient health outcomes per unit cost. The limited awareness of VBC among nurses might be attributed to the lack of specific operational guidelines in China. However, the majority's correct understanding and endorsement of the purpose of value-based healthcare suggest that it aligns with the nurses' values and goals for future medical practice.

The research in the attitudinal dimension reveals that the highest rate of agreement among participants is for value-based medicine-related courses, indicating that relevant courses could be developed to enhance nurses’understanding of value-based healthcare.According to research by Kuck et al. [6], The implementation of value-based healthcare in internal medicine is more feasible, indicating that relevant training courses could be initially offered to nurses in internal medicine departments.In addition, because some studies have shown that course information is difficult to find, it is recommended to teach courses through multiple channels and take advantage of online to make it more accessible to more people [7]. The concept of value-based healthcare should also be added to the curriculum training of medical students, so as to better promote value-based medicine [8]. Meanwhile, many participants expressed a lack of confidence in providing high-quality medical services, which may be due to the lack of a clear definition of what constitutes high-value and low-value medical services, as well as the absence of quantitative indicators for measuring value. At present, the mainstream method is to form a negative list through various physician associations, and then measure the degree of low-value services through the negative list [9]. In addition, many research subjects believe that digital transformation plays a key role in the promotion of value-based healthcare, because the informatization of Chinese hospitals is still insufficient, the quality of the homepage of medical records is not high, and it may be difficult to measure low-value services, and only a few low-value services can be measured [10, 11]. In addition, concerns about the increased management costs associated with VBC may be due to the lack of clarity about the cost and effectiveness of training, as training will certainly bring a lot of money and time costs, but there is a lack of training and practice in value-based medicine [12].

In practice, the study found that the reported incidence of low-value services was generally over 5% for both nurses’self-reports and reports about their colleagues, indicating a considerable number of low-value services in China. At the same time, there is a discrepancy between the incidence of low-value behaviors reported by nurses themselves and the incidence of low-value practices they reported among their colleagues, with the incidence of low-value services reported by nurses themselves being lower than that reported about their colleagues. This may be attributed to self-other moral bias, where nurses tend to believe that their own medical behaviors do not constitute low-value services when judging whether their own or their colleagues' actions are such services [13]. Among unnecessary medical practices, the incidence of ‘unnecessary laboratory testing’is relatively high.This may be due to the fact that laboratory testing is one of the most frequently performed activities in healthcare, and most tests are overused. The results of these tests either do not alter treatment decisions or can lead to errors in judgment, thereby posing risks to patients [14]. Additionally, among other low-value practices, ‘Insufficient Treatment’is reported relatively frequently.This may be because DRG payment is a prepaid healthcare payment method, where hospitals are responsible for the medical expenses that exceed the diagnostic group the patient is assigned to. Therefore, in order to obtain profits and ensure sustainable development, hospitals may reduce necessary service items or increase unnecessary ones, ultimately leading to impaired patient health.

The limitations of this study include: 1) The use of an online questionnaire format, which may introduce bias; 2) Reliance on self-reported data, which may be subject to inaccuracies; 3) A limited number of objective questions in the knowledge dimension, which may result in an imprecise exploration of understanding of value-based healthcare. Despite these limitations, this study is the first to conduct a KAP survey on value-based healthcare among Chinese nurses, featuring a multi-center and diverse sample, which adds significant value to the research.Future research could consider using offline questionnaires, incorporating hospital system data, and increasing the number of objective questions in the knowledge dimension to better reflect the actual situation.

Conclusion

This study is based on a survey of knowledge, attitudes, and practices (KAP) regarding value-based healthcare among nurses, and it has found that Chinese nurses currently have limited understanding of value-based healthcare. Furthermore, according to the research findings, there may be low-value healthcare practices in China, such as "unnecessary laboratory tests" and "insufficient treatment." Additionally, it was discovered that the incidence of low-value practices reported by nurses themselves was lower than that reported by their colleagues. These research findings suggest that promoting nurses' awareness of KAP through department-specific gradual promotion and online publicity, as well as investigating low-value healthcare practices using objective data such as hospital system data, could be effective strategies. This would facilitate the implementation of value-based healthcare in China and address potential deficiencies that may arise from new healthcare payment methods.