Does de-implementation of low-value care impact the patient-clinician relationship? A mixed methods study

Abstract

Background The importance of reducing low-value care (LVC) is increasingly recognized, but the impact of de-implementation on the patient-clinician relationship is not well understood. This mixed-methods study explored the impact of LVC de-implementation on the patient-clinician relationship. Methods Adult primary care patients from a large Virginia health system volunteered to participate in a survey (n = 232) or interview (n = 24). Participants completed the Patient-Doctor Relationship Questionnaire (PDRQ-9) after reading a vignette about a clinician declining to provide a low-value service: antibiotics for acute sinusitis (LVC-antibiotics); screening EKG (LVC-EKG); screening vitamin D test (LVC-vitamin D); or an alternate vignette about a high-value service, and imagining that their own primary care clinician had acted in the same manner. A different sample of participants was asked to imagine that their own primary care clinician did not order LVC-antibiotics or LVC-EKG and then respond to semi-structured interview questions. Outcomes data included participant demographics, PDRQ-9 scores (higher score = greater relationship integrity), and content analysis of transcribed interviews. Differences in PDRQ-9 scores were analyzed using one-way ANOVA. Data were integrated for analysis and interpretation. Results Although participants generally agreed with the vignette narrative (not providing LVC), many demonstrated difficulty comprehending the broad concept of LVC and potential harms. The topic triggered memories of negative experiences with healthcare (typically poor-quality care, not necessarily LVC). The most common recommendation for reducing LVC was for patients to take greater responsibility for their own health. Most participants believed that their relationship with their clinician would not be negatively impacted by denial of LVC because they trusted their clinician’s guidance. Participants emphasized that trusted clinicians are those who listen to them, spend time with them, and offer understandable advice. Some felt that not providing LVC would actually increase their trust in their clinician. Similar PDRQ-9 scores were observed for LVC-antibiotics (38.9), LVC-EKG (37.5), and the alternate vignette (36.4), but LVC-vitamin D was associated with a significantly lower score (31.2) (p < 0.05). Conclusions In this vignette-based study, we observed minimal impact of LVC de-implementation on the patient-clinician relationship, although service-specific differences surfaced. Further situation-based research is needed to confirm study findings.

Scoping review of interventions to de-implement potentially harmful non-steroidal anti-inflammatory drugs (NSAIDs) in healthcare settings

“…Fifth, outcomes important to patients were inconsistently assessed in the studies reviewed. Despite some evidence that patient satisfaction and trust are not adversely impacted by low-value care de-implementation,54 55 clinicians continue to cite concern about patient response as a predominant de-implementation barrier 24 56–58. In addition to evaluating patient-focused outcomes, future studies should explore the unintended consequences of the interventions.…”

Effect of a Peer Comparison and Educational Intervention on Medical Test Conversation Quality

“…We found patients trusted their physicians to offer only necessary tests. At the same time, physicians assumed their patients wanted more tests, though evidence suggests otherwise: patients wish their physicians talked to them about potential incidental findings before they occurred and report that their physicians de-implementing low-value screening tests would not harm patient-physician relationships and might even increase trust . What’s more, patients exposed to more low-value care do not rate their patient experiences more highly .…”

A Scoping Review of Interventions to De-implement Potentially Harmful Nonsteroidal Anti-inflammatory Drugs (NSAIDs) in Healthcare Settings

“…Second, outcomes important to patients were inconsistently assessed in the studies reviewed. Despite some evidence that patient satisfaction and trust are not adversely impacted by low-value care deimplementation, 57,58 clinicians continue to cite concern about patient response as a predominant de-implementation barrier. 24,[59][60][61] In addition to evaluating patient-focused outcomes, future studies should explore unintended consequences of the interventions.…”