Over this holiday season we are publishing our Editor’s picks of 2018 for you to read and enjoy again. The third and last one is by Derek Clewley.
The obvious answer to the question, why do people seek healthcare for musculoskeletal conditions might be because of pain, loss of function, or disability. To some degree, all of these reasons are suitable answers. However, as the British economist E.F. Schumacher once stated “everything can be seen directly except through the eye through which we see it”. Maybe, clinicians and researchers are unintentionally, or willfully, blinded to the true or alternative reasons to the question why people seek healthcare. It is likely that the answer to this question is much more complex than simply pain, function, or disability.
One of the most complex constructs to study is human behavior. Human behavior has been described and defined in a number of ways, but simplistically it is the way humans act and interact with each other and their environment. It is influenced by many things including genetics, cultural and social norms, and individual attitudes, values and beliefs. The answer as to why people seek healthcare for certain conditions (while others may not) is likely influenced to a large degree by behavioral features. Health seeking behavior defined is the sequence of remedial actions that an individual undertakes to rectify real or perceived ill health. Health seeking behavior has been studied extensively in population health, especially in attempts to explain why individuals do not utilize healthcare services. For instance, in attempts to resolve the Ebola Outbreak that occurred in West Africa in 2014, healthcare services were brought in to medically underserved areas. However, even though these services became readily accessible, many individuals did not seek out the necessary care brought in to fight the pandemic. Much of the studies on health seeking behavior are conducted to better understand underutilization of healthcare services.
The speculative paradox to underutilization of healthcare services is overutilization. Perhaps some individuals have a behavioral predisposition to use healthcare services at higher rates than others, regardless of the condition or symptoms. We recently published two studies that have shed some light on the role of health seeking behavior and healthcare utilization. Both studies used large cohorts of individuals in a health system that has excellent access to healthcare services. One study looked at spinal pain while the other used hip surgery. They both used one year pre-index healthcare utilization as a proxy measure of health seeking behavior. These patterns of utilization were analyzed to determine if they predicted future healthcare utilization after the indexed event. In both studies, health seeking behavior predicted future healthcare utilization, even after adjusting for physical and mental comorbidities, sex, age, and other confounding factors.
What does this mean?
The results from these studies indicate that individuals who are prone to seeking out healthcare services may continue to do so at higher rates after the onset of a musculoskeletal condition. However, one must be careful to resist the urge to over interpret these findings. While both studies adjusted for a number of confounding factors, human behavior is far too complex to adequately control for all influencing variables. Furthermore, we do not know if those that sought healthcare services at higher rates had better or worse outcomes. Essentially, we cannot draw any conclusions about the value of healthcare seeking especially for musculoskeletal disorders. Perhaps those that seek healthcare services for musculoskeletal conditions have better outcomes. In the Ebola Outbreak example, it is fair to assume that the value of seeking those services would be high and therefore resources should be considered to improve the utilization of these services. In fact, there is literature to support those that seek services for certain conditions have lower mortality rates and better outcomes. As previously stated, human behavior is complex, and maybe there exists a sliding scale where certain amounts of health seeking behavior are distinctively appropriate for different diseases and conditions. Therefore, future studies that begin to unravel these complexities, including those that consider health related outcomes, will be crucial.
Why is this important?
Overutilization of healthcare services has often been considered to be influenced by the health system and the healthcare provider. However, lost in this equation are the patients themselves. Studies investigating health seeking behavior will help to fill this void. With that said, one cannot fault patients that aggressively seek out healthcare services if access to care is readily available and cultural and societal factors facilitate these behaviors. Ultimately, the provider and health system help to facilitate health seeking behavior. Therefore, clinicians should be aware of an individual’s behavioral predisposition to utilize healthcare services and be aware of the potential influence this may have on the management of the patient’s condition. One way clinicians might do this is by addressing prior healthcare utilization, not only for the condition being managed but for all potential health concerns. Additionally, there may be value in identify the patient’s expectations, beliefs, and attitudes towards the health system. This qualitative information gathering could provide details about how much the patient expects to gain from seeking healthcare and the role the health system might provide. Knowing these details may allow the provider to set expectations about the care the patient will receive in order to achieve the appropriate outcomes.
About Derek Clewley
Dr Clewley is an educator, researcher, physical therapist, and mentor in the Duke University Doctor of Physical Therapy program. His clinical area of expertise and training is orthopaedics and manual physical therapy. He has achieved board certification in orthopaedics, and is recognized as a Fellow of the American Academy of Orthopaedic Manual Physical Therapists. His primary research interest is focused on the behavioral aspects of health services utilization for musculoskeletal conditions. Dr Clewley has extensive experience in the development of continuing education, residency, and fellowship post graduate training programs. He has presented at numerous conferences and has been published in peer reviewed journals.
Derek Clewley, Dan Rhon, Timothy Flynn, Shane Koppenhaver, Chad Cook (2018). Health seeking behavior as a predictor of healthcare utilization in a population of patients with spinal pain. PLOS One https://doi.org/10.1371/journal.pone.0201348. Open Access! FREE to download