Messaging Strategies to Enhance Patients' Vague Understanding of Low-Value Care

Low-value care and its detrimental effects have in recent years become a hot topic in medical circles, but a new study suggests that many patients many not be aware of why the concept matters or what the term even means.

As healthcare providers and payers seek opportunities to cut wasteful spending, an obvious target is low-value care consisting of unnecessary tests and treatments. The Choosing Wisely initiative enacted in 2012 has been embraced by numerous medical societies, but public understanding of the campaign and its aims is undetermined. In light of this gap in evidence, a recent study published in the Milbank Quarterly set out to assess consumers’ perceptions of low-value care through focus groups, interviews, and surveys.

Although the Choosing Wisely messaging campaign has attempted to reinforce the idea that low-value care is wasteful and harmful to society, the study participants rarely cited cost or waste as a disadvantage to these services, instead expressing concerns about the personal burdens on their own time. About two-thirds could name something that low-value care might entail, but only 5.6% specified that excessive care could harm patients and just 1% associated low-value care with personal or societal costs.

When asked how reducing the incidence of low-value care could prove beneficial, respondents commonly said that it would improve patient-provider communication, as the clinicians might interact with them more if their time was not so consumed by extensive tests and treatments. They also voiced hopes that it would lead to more personalized medical care.

The researchers found significant disparities in public understanding of low-value care, as they determined that increasing education levels were associated with better awareness of the concept and greater willingness to reject unnecessary services. Compared with those who had graduated college, the respondents who did not complete high school were 2-and-a-half times more likely to be unable to explain what it would mean for a clinician to avoid low-value care and half as likely to anticipate any benefits from clinicians who did avoid such care. Minority respondents were less likely to express an understanding of low-value care, even after accounting for differences in educational attainment and health status.

According to the study authors, these findings suggest that the current Choosing Wisely messaging campaign may not be optimally framing the issue of low-value care. To test alternative strategies, the researchers conducted surveys after assigning respondents to read 1 of 4 newspaper stories that emphasized different themes surrounding low-value care.

For instance, after reading an article that reinforced the health threats of low-value care, participants were more likely to know that excess care could harm health, but less likely to report awareness of other themes like the associated waste or the need to question clinicians’ decisions. When respondents successfully identified both messages of harm and waste associated with low-value care, they were more likely to avoid excess care in hypothetical situations. For those with no prior knowledge of low-value care, the harm message was much more effective than the waste message at changing attitudes and behaviors.

The researchers summarized that while patients appear to be willing to forego excess care if they can identify the potential benefits, the current coverage strategy of linking low-value care to waste has not effectively resonated with patients and increases the likelihood that they will blame the problem on their providers. Instead, an approach that links low-value care to both waste and health risks would be more effective, and these media strategies should emphasize the strengthened patient-centered relationships that can arise when low-value care is reduced.

“Most crucially, our study highlighted the fact that Americans want relationships with clinicians that are more relational than mechanical and that are deeply humane, personalized, and interactive,” they concluded. “Partnerships between patients and clinicians to ‘choose wisely’ with respect to tests and treatments seem most likely to thrive when associated with these key values.”