SRFP002: A Qualitative Analysis of Patient Perspectives on Low Value Healthcare and the Patient-Clinician Relationship

Kenan Michaels, BA; John Epling, MD, MSEd; Michelle Rockwell, PhD, RD

Abstract

Context: Low value healthcare (LVC) is defined as medical interventions that provide no direct benefit to patients. Many initiatives have sought to identify and reduce this type of healthcare spending, waste, and possible harm; however, little research has focused on patients’ perspectives and the impact of de-implementation on the patient-clinician relationship. Objective: To characterize patients’ understanding of LVC as well as the impacts of clinician-driven attempts to reduce LVC on the patient-clinician relationship. Study Design: A qualitative study consisting of semi-structured phone interviews including a vignette that described a clinician’s decision not to provide LVC services such as antibiotics for acute sinusitis or a LVC screening EKG. Interview prompts also included impressions of the low value service and the perceived impact of LVC de-implementation. Content analysis was performed iteratively to develop a codebook and themes from the interview transcripts. Setting: Primary care patients of a large, tertiary healthcare system (1 million patients, 45 primary care centers) in SW Virginia who were recruited by random email sampling (n=500). Population studied: Participant (n=24) demographics mirror the local primary care patient population: 54.8 years of age, 54% female, 83% White, 33% Medicare/8% Medicaid/58% Commercial. Outcome measures: Overarching themes. Results: Participants had a broad range of understanding of LVC. All participants agreed that they would not want an unnecessary antibiotic prescription yet some felt that they would want to receive a screening EKG. Many also equated LVC with low quality care and were motived to share corresponding stories about a prior negative experience. Despite this, the majority of patients indicated that they place great trust in their clinicians and rely heavily on their direction, likely assisted by the presence of strong communication, trust, and a genuine demeanor. Indeed, more than half of patients stated that the denial of a desired service by their clinician would not negatively affect their relationship. Conclusions: Minimal evidence was seen to indicate that the patient-clinician relationship would be negatively impacted by de-implementation of LVC. Future successful efforts to reduce LVC would benefit from further inquiring about the patient perspective, studying the patient-clinician relationship, and leveraging the deep trust that patients have in their clinicians.
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Dennis Baumgardner, MD
11/19/2021

Very well done study, poster and oral presentation. Thank you! Dennis

Kenan Michaels
kenan.michaels@gmail.com 11/23/2021

Thank you for your kind words Dr. Baumgardner!

John Epling
jwepling@carilionclinic.org 11/20/2021

Great work on this project, Kenan!

Kenan Michaels
kenan.michaels@gmail.com 11/23/2021

So appreciate you bringing me on board!

Jack Westfall
jwestfall@aafp.org 11/21/2021

Terrific poster and presentation. Thanks for your work.

Kenan Michaels
kenan.michaels@gmail.com 11/23/2021

Thank you Dr. Westfall! I appreciate your kind words!

Gillian Bartlett
gillian.bartlett@health.missouri.edu 11/21/2021

As someone deeply interested in patient-provider communication, this was a fascinating read. I think this would be very reassuring to a lot of clinicians who might be hesitant to reduce LVC. We can certainly do a better job communicated exactly what LVC is to patients - nice presentation and I look forward to seeing more work in this area.

Kenan Michaels
kenan.michaels@gmail.com 11/23/2021

Thank you Dr. Bartlett for checking out my poster, your comment, and leadership with NAPCRG! I was very excited to be included this year. Completely agree that we should make patients more aware of LVC!

William R. Phillips
wphllps@uw.edu 11/21/2021

Very important Fascinating research question. I agree, next steps should include more foundational qualitative work on clinician- patient understanding of what constitutes low value, shared decision-making and setting patient oriented goals. Thanks for sharing your work here at NAPCRG. - Bill Phillips

Kenan Michaels
kenan.michaels@gmail.com 11/23/2021

Thank you Dr. Phillips for your comment and kind words. Was an honor to be included in this year's conference!

Diane Harper
harperdi@med.umich.edu 11/22/2021

you have defined low value care, but who makes the decision of what is low value care? Thank you for sharing your work with NAPCRG!

Kenan Michaels
kenan.michaels@gmail.com 11/23/2021

Thank you Dr. Harper for your question and kind words! For this study, we used the Choosing Wisely specialty-specific guidelines to inform our definition of "low-value care". Smarter Care Virginia, a local state-specific initiative with the Virginia Center for Health Innovation, had identified the screening EKG and antibiotics for acute URI as two specific LVC interventions of interest!

maret felzien
11/23/2021

Interesting.  So glad you asked for patient feedback. Were patients at all part of the design or thematic analysis along the way?  

Kenan Michaels
kenan.michaels@gmail.com 11/23/2021

Maret, thank you for your question! The patients were not directly involved in the design or thematic analysis, we felt that it was important for them to be somewhat "blinded" to our aims and question intent. Including them would absolutely be something to consider in the future! 

Arturo Martinez
arturo.martinez.guijosa@gmail.com 11/23/2021

Great poster and video to help describe your research. As a community member, low value care seems like something that should not exist and therefore agree to decrease. However, how do providers build the trust and relationships with patients so that LVC can be avoided and there is trust both ways?

Kenan Michaels
kenan.michaels@gmail.com 11/23/2021

Arturo, I appreciate your question and kind words! We heard a couple of themes and comments that we heard from the patients along the lines of your very question; here are a couple that stuck out to me that increase patient trust: 1) Doctors using clinical language that community members can understand 2) Doctors maintaining a patient relationship over many years. We heard that the longer someone was with a doctor, then more they were trusted 3) Some patients really liked a doctor who was "like them" i.e. similar race, background, SES... 4) Doctors spending adequate time with each patient in the office

Kirk Mason
kirk@kirkmason.ca 11/23/2021

Fascinating work! If you take this further or run something similar again, I'd love to know the statistics behind a similar question: "If your physician does not provide you a desired intervention, HOW does that effect your trust?" or something to that effect. Your video indicated that some people answering 'maybe' might have had a change in their trust by being denied LVC, and that change was actually in a positive direction. Trust is such an important topic in healthcare right now - I'm excited to see more work in this area!

Kenan Michaels
kenan.michaels@gmail.com 11/23/2021

Thank you for your comments Kirk! Those that said "maybe" had many reasons why. Usually they would follow up their "maybe" with statements along the lines of "it would depend on how my doctor phrased the refusal" or "As long as my doctor spent time explaining why, I would be ok with the refusal." I hope that's helpful! And yes, you're exactly right - many specifically mentioned INCREASING trust with an adequately-explained doctor refusal. Certainly we should be leveraging that! 

Andy Pasternak
avpiv711@sbcglobal.net 11/26/2021

Cool twist on looking at LVC. Really nice study. Did you see any differences by gender/race/SES?

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