Background
Methods
Demographics | Vignette^ | Domains | |
Qualitative INTERVIEW (n = 24) | Age Gender Race Ethnicity Insurer Education Level Annual Income Region PCP License‡ | Researchers read one vignette (randomly assigned) to each interview participant. LVC-antibiotics (denied) LVC-EKG (denied) | 1. understanding of the concept of LVC 2. recognition of reasons for not providing LVC 3. the impact to the patient of not providing LVC 4. the impact to the patient-clinician relationship of not providing LVC 5. patients’ recommendations for the reduction or de-implementation of LVC |
Demographics | Vignette^ | PDRQ-937 | |
Quantitative SURVEY (n = 232) | Age Gender Race Ethnicity Insurer Education Level Annual Income Region† PCP License‡ | Survey respondents read one vignette (randomly assigned) at the start of the survey. LVC-antibiotics (denied) LVC-vitamin D (denied) LVC-EKG (denied) HVC- statin for high CVD risk (alternate) (prescribed) | You will read nine statements that a person can make about his/her primary care provider (PCP). Please choose the appropriateness of each statement for your PCP by marking one number per statement. 1 = not at all appropriate 2 = somewhat appropriate 3 = appropriate 4 = mostly appropriate 5 = totally appropriate 1. My PCP helps me. 2. My PCP has enough time for me. 3. I trust my PCP. 4. My PCP understands me. 5. My PCP is dedicated to helping me. 6. My PCP and I agree on the nature of my medical symptoms. 7. I can talk to my PCP. 8. I feel content with my PCP’s care. 9. I find my PCP easily accessible. |
Interview and survey data were integrated for analysis and interpretation. |
Interview administration
Survey administration
Data analysis
Interview
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-Did the interview participant comprehend the concept of LVC as related to this service? (yes, no, or maybe/unclear)
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-Did the interview participant agree with the clinician’s decision to not provide or de-implement the service being discussed? (yes, no, or maybe/unclear)
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-Did the interview participant indicate that not providing or de-implementing the service would impact their relationship with their primary care provider? (yes, no, or maybe/unclear)
Survey
Data integration
Results
n | Age (years) | Gender n(%) | Race n(%) | Ethnicity n(%) | Insurer n(%) | Education n(%) | Annual Income n(%) | PCP License | |
---|---|---|---|---|---|---|---|---|---|
Interview | 24 | 54.8 ± 12.2 | 13(54) female | 20(83) white | 23(96) non-Hispanic | 14(58) Commercial 8(33) Medicare 2(9) Medicaid 0(0) Other | 8(33) < High school 9(38) College 7(29) Graduate 0(0) Other 00) Prefer to not say | 1(5) <$25,000 6(25) $25 to 75,000 13(55) $75 to 125,000 1(5) $125 to 175,000 1(5) >$175 1(5) Unsure/Prefer to not say | 19(79) MD/DO 1(5) NP 4(17) PA |
Survey | 232 (n = 65) LVC-antibiotics (n = 54) LVC- vitamin D (n = 59) LVC-EKG (n = 54) HVC-statin | 53.4 ± 15.9 | 151(65) female | 216 (93) white | 223(96) non-Hispanic | 135(58) Commercial 70(30) Medicare 14(6) Medicaid 14(6) Other | 49(21) < High school 104(45) College 72(31) Graduate 5(2) Other 5(2) Prefer to not say | 23(10) <$25,000 84(36) $25 to 75,000 60(26) $75 to 125,000 21(9) $125 to 175,000 14(6) >$175 32(14) Unsure/Prefer to not say | 167(72) MD/DO 49(21) NP 16(7) PA |
Aim 1: how do patients respond to the de-implementation of low-value care?
Comprehension of low-value care
“I just don’t see the harm in it. If a person has insurance and insurance is going to cover it and I can make my copay, what’s the harm in it?” (PT18)“I think it’s more based on patient preference, like if the patient is pressing it…that’s when I would go ahead and get one done…just as a precaution.” (PT21)
“…they try every test under the sun and at the end, they almost always turn out the same way every time…I guess that’s what they are programmed to do. It’s an example of overkill…and in one case, he got an incorrect diagnosis and the trail of new problems and test started from there…but none that actually helped.” (PT14)“A lot of times with elderly people…they would send for an ambulance and take her to the emergency room and then this whole cascade of tests started, you know…but at some point…there is the law of diminishing returns on bringing out the full battalion or whatever.” (PT17)
Thoughts, feelings, and memories triggered by the topic of low-value care
“There’s a certain amount of time that physicians are kind of supposed to spend with their patients. It’s like there’s a countdown when you enter the room, I wish they would stop that…it makes people just feel like a number…herded in and herded out.” (PT05)
“…my physician is a very thoughtful and brilliant doctor, and I think she’s trying to do a good job for me. That’s her whole mission in life, I can just tell…I trust her entirely and she takes care of me.” (PT14)“He listens and to tell you the truth, he knows more about me, more personal things, than literally anyone else in my life. I trust him is why…I trust him more than most anyone I know.” (PT19)I think that trust and confidence that your PCP really listens and knows you matters. It’s a rather intimate process if it’s done right.” (PT15)“[My doctors] are people I can trust and I do trust. That is good fortune to have in your life.” (PT16)“It is extremely reassuring to have the trust in your provider that I have in my doctor.” (PT11)
Recommendations for reducing the utilization of low-value care
Aim 2: does low-value care de-implementation impact the patient-clinician relationship?
“I’ve had that issue with a medication before, when the doctor and me did not agree on which medication to go on. We actually went with the one they recommended because I figure I have been with him awhile and trust him so kindof sensed that their judgement should be over mine.” (PT21)“My doctor would never do that but other doctors don’t think about how the outcome will be for their patients.” (PT19)
“Actually, if my provider lets me know that a service isn’t really necessary for me, it would enhance my trust in her.” (PT22)“There's rules that the doctors have to go by as well, as far as giving good care. This includes rules for not overprescribing and doing too much…I wouldn't be happy with that doctor. I want a doctor who follows the rules.” (PT03)
“The patient said she would be lying if she said it didn’t [impact trust]. She had a recent issue related to this and now realizes her physician was making the better recommendation. She has used it as a learning experience.” (KM, interview notes)“I wanted a particular procedure. And the doctor said - No, this one's better for you and here's why…And he could explain to me why it wasn’t a good option. Even though I was irritated to begin with, when I sat back and thought about it and did a little more research, I said ‘Okay, he's right.’ I got right over myself.” (PT13)