Low-value Care Misunderstood By Patients

A Yale study finds that while patients have difficulty envisioning the benefits of avoiding low-value care, they are clear on one point: They would like doctors to spend more time talking and less time testing.

Choosing Wisely has become a healthcare call-to-action not unlike the "triple aim" and, increasingly, "measures that matter."

The doctor-driven campaign to reduce the use of unnecessary care needs to reach two audiences, doctors and patients. Its message to doctors: Think twice before ordering that test or starting that treatment. Its message to patients is less clear, according to a study out of Yale.

The Yale study cites the Choosing Wisely campaign throughout, but its aim was to look, not at that program specifically, but at how well the public understands the concept of low-value care.

The paper found one-third of those surveyed "have difficulty envisioning benefits from avoiding low-value care."

Unwise Medical Choices Stubbornly Defy Eradication

Mark Schlesinger, a professor of health policy at the Yale University School of Public Health, is the lead author of the study. He lauds the American Board of Internal Medicine, which launched and shepherds the Choosing Wisely campaign, but says ABIM has "a hard message to communicate."

The study, which appeared in the Millbank Quarterly, involved focus groups, interviews and a national survey of more than 900 people. They were asked questions such as this:

"People will sometimes talk about doctors being especially good at avoiding tests and treatments that are likely to have more risk than benefit. If you were to hear or read that a particular doctor was good at this, what—if anything—would you expect them to do differently from most other doctors?"

The researchers found that two-thirds of those surveyed "had some sense of what low-value care might entail, though many were uncertain about the specifics." Additionally:

• Many who offered a description of low-value care saw it in terms of only testing, not treatment.

• About 5% "anticipated that excessive medical care might harm patients."

• About 1% made a link between low-value care and medical costs – either their own or the nation's.

Even though some healthy respondents could not envision how unneeded tests could be harmful, patients with a history of serious illness knew exactly what it meant. Many reported "personal exposure to duplicated tests."

Patients were more concerned about the "opportunity costs," the use of time off or other resources needed to receive treatments with little clinical value. That was an issue for lower-income patients "whose life circumstances often make it challenging to find time for needed medical care."

What is 'Low-Value' Care?
Researchers also found disparities in patients' ability to define low-value care. They asked respondents to offer a description of what it would mean for a doctor to avoid low-value care. College graduates were much more likely than those without a high-school degree to offer a description. All minority groups were less likely than whites to be able to describe what avoiding low-value care might involve.

Schlesinger says ABIM has tried to reach out to patients through its affiliation with Consumer Reports. But, it may reach mainly highly educated, savvy consumers and not "the general public as well," he says.

The paper states: "The public's awareness of low-value care is incomplete, with substantial disparities related to race, ethnicity, and socioeconomic status."

Schlesinger says that once they were done with their eight focus groups, it became clear what patients want their doctors to do more of, talk to them.

They had a hard time imagining that a test could be bad for them, but he says they would be willing to put off tests in exchange for more time with their doctors.

'Start Simple'
"What we heard a lot from people was that they were happy if their clinicians would start simple with them," Schlesinger says. "Start by talking to them. Start with simple test and treatment, and always have the option of going to the more expensive, the more elaborate, the more invasive."

They don't want to be told they can never have those tests. "They were looking for the kind of care that would be more personalized and more personal than just throwing tests and treatments at them," he says.

Lessons
"The big threat that they saw was that doctors would become routinized, mechanized, and technology-centric rather than person-centric."

Daniel Wolfson, chief operating officer of the ABIM Foundation, believes there is much to learn from the Yale study. One key message is the willingness of patients to forgo some care for more time with a doctor.

But Wolfson does not think the study is designed to measure whether patients are getting the Choosing Wisely message. He sees it as a look at the language that is used to frame the discussion, noting that the ABIM doesn't use the term "low-value care" because it doesn't resonate well with patients.

Choosing Wisely is not meant to be a general public awareness campaign, Wolfson says. It is meant to start conversations. Many will occur between patient and clinician at the point of care.

In addition to those chats, Choosing Wisely has launched a national discussion about overuse, a topic that was once erroneously associated with a move toward rationing and so-called death panels, Wolfson says.

"Now we are having a rational conversation about important issues," he says.