Patient request amplifies other determinants of providing low value care: A factorial survey experiment in physicians’ decision-making

Abstract

Background Low-value care (LVC) is a term describing practices that persist in healthcare, despite being ineffective, inefficient, or causing harm. The professionals are central in the challenge of de-implementing LVC as they ultimately decide whether or not to provide a particular practice. Several determinants for the provision of LVC have been identified, but understanding how these factors influence professionals’ decisions, individually or together, is a necessary next step to guide de-implementation. This study addresses the gaps in understanding how primary care physicians make decisions about providing LVC, by experimentally testing the influence of different determinants related to their decision-making. Methods A factorial survey experiment was employed, using vignettes that presented hypothetical medical scenarios among 593 primary care physicians across Sweden. Each vignette varied systematically by factors such as patient age, patient request for the LVC, physician’s perception of this practice, practice cost to the primary care center, and time taken to deliver it. For each scenario, we measured the reported likelihood of providing the LVC. We also collected information about the physician’s age, work experience, and their general worry about missing a serious illness. Results Multilevel modeling revealed that patient request and physicians’ positive perceptions of the LVC were the factors that most impacted the decisions to provide it. Additionally, when the LVC was described as being low cost or not time-consuming, patient request increased the reported likelihood of providing it. On the other hand, credible evidence against the LVC and its high cost reduced the role of patient request. Furthermore, physicians’ fear of missing a serious illness was linked with higher likelihood of providing LVC, and the credibility of the evidence against the LVC reduced the role of this anxiety in decisions. Conclusions The findings highlight the dominant role of patient requests and the mitigating effect of evidence credibility. Strategies to reduce LVC should include enhancing physicians’ communication skills and incorporating decision-support tools to better manage patient expectations and align clinical practices with current evidence.