Introduction
Patient demand - and provider perception of patient demand - contribute to the delivery of low-value care.1–3 To inform future implementations of a Choosing Wisely® campaign to reduce low-value care, we assessed why patients at an urban safety net urgent care clinic seek care for upper respiratory infections (URIs) and lower back pain (LBP)—two conditions commonly associated with low-value care.
Methods
Trained bilingual (English + Spanish) research associates (RAs) invited patients waiting at Los Angeles County + University of California’s Medical Center’s Urgent Care Clinic to complete an in-person survey; RAs entered responses into iPads using REDCap ©. Patients were eligible if they were 18 years or older, spoke English or Spanish, demonstrated cognitive capacity to provide verbal consent to participate, and were seeking care at the clinic for any kind of complaint. Participants who were seeking care for a current URI or LBP were administered a survey with items measuring reasons for seeking care modified from a previously published survey,4 beliefs about antibiotic resistance, and preferred health information sources. Patients seeking care for any other condition but who sought care for URI or LBP in the past were administered a survey with items referring to their previous experiences seeking care for the URI or LBP, beliefs about antibiotic resistance and preferred health information sources. Another 40 participants who had never sought care for a URI or LBP were administered a survey with items about preferred health information sources only. The survey was written at a 6th grade reading level, translated into Spanish, and pilot-tested with cognitive interviewing of 20 Latinos (age ~50–70 years, 10 volunteers in each language) to measure face validity and ensure comprehension. RAs asked survey questions verbally, allowing participants to provide open-ended responses which were categorized into the response set options by the RA (internet and social media separate). We calculated response frequencies using simple descriptive statistics.
Results
Between November 21, 2016 and January 16, 2017, RAs invited approximately 250 patients to participate; 1 was ineligible (cognitive impairment), and most agreed; 200 patients completed a survey. Table 1 summarizes the participants’ characteristics. A majority of the participants identified themselves as Latino/Hispanic (84%) and over half opted to complete the survey in Spanish (66%).
Table 1.
Characteristics of Sample (n=200)
| Characteristic: | Total Sample (n=200) | Asked about current URI (n=30) | Asked about previous URI (n =50) | Asked about current LBP (n=37) | Asked about previous LBP (n=43) |
|---|---|---|---|---|---|
| Mean age in years (range) | 48 (18–83) | 43.9 | 48.1 | 48.4 | 49 |
| Female, n (%) | 128 (64%) | 20 (66%) | 31 (62%) | 22 (59%) | 30 (69%) |
| Latino/Hispanic n (%) | 168 (84%) | 27 (90%) | 41 (82%) | 31 (83%) | 37 (86%) |
| Completed survey in Spanish, n (%) | 132 (66%) | 22 (73%) | 27 (54%) | 26 (70%) | 29 (67%) |
| < High school education, n (%) | 92 (46%) | 16 (53%) | 19 (38%) | 18 (48%) | 17 (39%) |
| Has health insurance, n (%) | 132 (66%) | 18 (60%) | 38 (76%) | 23 (62%) | 30 (69%) |
| Has regular doctor, n (%) | 112 (56%) | 14 (46%) | 36 (72%) | 16 (43%) | 28 (65%) |
Patients with current and previous URIs reported wide variation in reasons for seeking care (Table 2). For patients with current URIs, the most frequently reported reasons for seeking care was for an exam (53%) and for antibiotics (50%), while respondents with previous URIs most frequently reported seeking medication other than antibiotics (58%) and advice on how to feel better (56%). Among those with a previous URI, over half (52%) reported receiving an antibiotic prescription after their visit, while only 32% reported receiving advice on how to feel better. Among all surveyed URI patients (current and previous), 65% agreed “germs are getting harder to treat with antibiotics,” while 45% agreed that “antibiotics should be prescribed for a common cold” some of the time or more often (Table 3).
Table 2.
Reasons for seeking health care among patients with current or previous URI or LBP
| Why did you come to see the doctor about your cough, chest cold, bronchitis or sinus infection? | Patients with Current URI (n=30)* | Patients with Previous URI (n=50)* | |
|---|---|---|---|
| What actions did your doctor take when you came to see them about your cough, chest cold, bronchitis or sinus infection? | |||
| get a doctor’s note | 8 (27%) | 11 (22%) | 3 (6%) |
| an exam or test | 16 (53%) | 19 (38%) | 24 (48%) |
| advice about how to feel better | 14 (47%) | 28 (56%) | 16 (32%) |
| reassurance | 7 (23%) | 9 (18%) | 9 (18%) |
| a prescription for antibiotics | 15 (50%) | 19 (38%) | 26 (52%) |
| other medicine | 12 (40%) | 29 (58%) | 36 (72%) |
| other: | 8 (27%) | 2 (4%) | 10 (20%) |
| Why did you come to see the doctor about your back pain? | Patients with Current LBP Pain (n=37) | Patients with Previous Back Pain (n=43) | |
| What actions did your doctor take in regard to your back pain? | |||
| get a doctor’s note | 3 (8%) | 3 (7%) | 6 (14%) |
| find out what is wrong | 27 (73%) | 27 (63%) | 24 (56%) |
| physical exam | 20 (54%) | 22 (51%) | 26 (60%) |
| a test | 26 (70%) | 16 (37%) | 28 (65%) |
| advice about how to feel better | 11 (30%) | 10 (23%) | 9 (21%) |
| reassurance | 3 (8%) | 1 (2%) | 2 (5%) |
| referral to other specialist | 5 (14%) | 7 (16%) | 12 (28%) |
| a prescription for medicine to help the pain | 27 (73%) | 26 (60%) | 32 (74%) |
| other medicine | 11 (30%) | 7 (16%) | 18 (42%) |
| other | 3 (8%) | 2 (5%) | 5 (11%) |
Table 3.
Beliefs on antibiotic prescription for current and previous URI.
| How often do you think antibiotics are needed for the common cold? | Patients with Current and Previous URI (n=80)* |
|---|---|
| Never | 9 (11%) |
| Rarely | 30 (38%) |
| Some of the time | 29 (36%) |
| Most of the time | 4 (5%) |
| All the time | 3 (4%) |
| I don’t know | 2 (3%) |
| How often do you think that antibiotics are needed for bronchitis? | |
| Never | 3 (4%) |
| Rarely | 9 (11%) |
| Some of the time | 22 (28%) |
| Most of the time | 22 (28%) |
| All the time | 11 (20%) |
| I don’t know | 7 (9%) |
| Please tell me if you agree or disagree with the following sentence: “Some germs are becoming harder to treat with antibiotics” | |
| Strongly Disagree | 6 (8%) |
| Disagree | 15 (19%) |
| Do not Agree or Disagree | 2 (3%) |
| Agree | 43 (54%) |
| Strongly Agree | 9 (11%) |
| I don’t know | 4 (5%) |
| I don’t understand | 1 (1%) |
Reasons for seeking care also varied for LBP patients (Table 2), but a majority of those seeking care for current back pain reported seeking a prescription for pain medicine (73%), finding out what was wrong (73%), and/or receiving a test (70%).
Reponses among previous LBP patients were similar; the two most commonly reported reasons for seeking care in the past were to find out what was wrong (63%) and seeking a prescription for pain medication (60%). A majority of previous LBP patients reported receiving a prescription for pain medication (74%), a test (65%), and/or a physical exam (60%). For both URIs and LBP patients, seeking reassurance was rarely endorsed as a reason for seeking care or as care received (less than 13%).
When asked where they received health information, 80% of patients reported “from healthcare providers.” Other common responses were “family or friends” (61%), and “pamphlets” (55%). Social media was the least popular source reported (5%).
Discussion
In this convenience sample of mostly Latino patients waiting at an urban safety net urgent care clinic, most respondents seeking care for URIs and LBP (either current or previous) sought care in order to receive medications and/or an exam or test; though most sought advice on “how to feel better” very few came seeking reassurance. Half of current URI patients surveyed reported seeking antibiotics, while nearly three quarters of those with LBP came in order to receive pain medication. Physician behavior (possibly from previous visits) may be responsible for these expectations: it is notable that even when patients came seeking advice they largely reported receiving an exam/test or another prescription. One patient-centered solution to this mismatch might be for patients to complete a survey of expectations in the waiting room that would be available to the clinician at the point of care.
Our finding that most patients believed that antibiotics should be prescribed for common colds is consistent with previous work showing that patients frequently hold inaccurate beliefs about the efficacy of antibiotics for URIs,5–7 but it is disheartening that this remains true despite several public health campaigns over the past decades to reduce inappropriate prescribing.8,9 Our findings also show that despite recognizing the growing problem of antibiotic resistance, patients still seek antibiotics for themselves personally. Our findings are specific to urban Latino patients seeking care at a safety-net hospital; public health campaigns should be carefully tailored to reach Spanish-speaking populations.
It is remarkable that even with health information resources readily available across all forms of media, patients in this setting still consider their physicians their number-one source for healthcare information. This finding is especially interesting in light of recent data showing that physicians are most likely to support financial penalties for low value care when they consider harm to their patients (as opposed to harms to society or their institution).10 Leveraging the strength of this patient-physician relationship might prove useful not only for physician-level interventions to reduce low value care but also for educational interventions to disseminate healthcare information to patients.
Our study had important limitations, including the use of a convenience sample at a single academic medical center and the potential role of recall bias among patients with previous URIs or LBP. Due to the survey design, we cannot be certain that patients with LBP who wanted “a test” (vague word) wanted unnecessary imaging; nor can we know whether patients who wanted an antibiotic only if recommended by the clinician were categorized as coming “for antibiotics.” Perhaps more respondents would have volunteered they were seeking reassurance if this was suggested as an option or if they knew they had a serious concern.
Nonetheless, we conclude: 1) because the majority of patients with current back pain in this study expected prescription medications, these study findings inform us that ongoing initiatives to reduce opioid prescribing might be more effective if they include non-opioid prescriptions (for example ibuprofen); 2) campaigns to decrease inappropriate antibiotics might increase impact by focusing less on the abstract concern of antibiotic resistance on a population level and more on other motivators, such as the personal consequences of antibiotics (for example, toxicity); and 2) such an educational campaign might be most effective coming directly from personal healthcare providers.
Acknowledgements:
We are thankful for the help of Dr. Ali Stirland at Los Angeles County Health Agency (Department of Public Health) for her work on the survey and comments on an earlier version of this manuscript.
Funding Sources:
This work was supported by a grant from the American Board of Internal Medicine Foundation (ABIMF) “Spreading Choosing Wisely in Communities, Health Systems, Hospitals and Medical Groups.” Dr. Mafi was supported by an NIH/National Center for Advanced Translational Science Institute KL2TR001882 Award (PI: Mitchell Wong). Dr. Sarkisian was supported by the National Institute on Aging of the National Institutes of Health Midcareer Award in Patient-Oriented Research (1K24AG047899), the UCLA Resource Center for Minority Aging Research/Center for Health Improvement of Minority Elders (RCMAR/CHIME), and the NIH/National Center for Advancing Translational Science (NCATS) UCLA CTSI (UL1TR001881). Support for this paper has also been provided to the UCLA Value-Based Care Research Consortium (VBCRC) from the UCLA Vatche & Tamar Manoukian Division of Digestive Diseases.
Footnotes
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Conflicts of Interest: None
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