Screening primary-care patients forgoing health care for economic reasons

PLoS One. 2014 Apr 3;9(4):e94006. doi: 10.1371/journal.pone.0094006. eCollection 2014.


Background: Growing social inequities have made it important for general practitioners to verify if patients can afford treatment and procedures. Incorporating social conditions into clinical decision-making allows general practitioners to address mismatches between patients' health-care needs and financial resources.

Objectives: Identify a screening question to, indirectly, rule out patients' social risk of forgoing health care for economic reasons, and estimate prevalence of forgoing health care and the influence of physicians' attitudes toward deprivation.

Design: Multicenter cross-sectional survey.

Participants: Forty-seven general practitioners working in the French-speaking part of Switzerland enrolled a random sample of patients attending their private practices.

Main measures: Patients who had forgone health care were defined as those reporting a household member (including themselves) having forgone treatment for economic reasons during the previous 12 months, through a self-administered questionnaire. Patients were also asked about education and income levels, self-perceived social position, and deprivation levels.

Key results: Overall, 2,026 patients were included in the analysis; 10.7% (CI95% 9.4-12.1) reported a member of their household to have forgone health care during the 12 previous months. The question "Did you have difficulties paying your household bills during the last 12 months" performed better in identifying patients at risk of forgoing health care than a combination of four objective measures of socio-economic status (gender, age, education level, and income) (R(2) = 0.184 vs. 0.083). This question effectively ruled out that patients had forgone health care, with a negative predictive value of 96%. Furthermore, for physicians who felt powerless in the face of deprivation, we observed an increase in the odds of patients forgoing health care of 1.5 times.

Conclusion: General practitioners should systematically evaluate the socio-economic status of their patients. Asking patients whether they experience any difficulties in paying their bills is an effective means of identifying patients who might forgo health care.

Publication types

  • Multicenter Study
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adolescent
  • Adult
  • Aged
  • Aged, 80 and over
  • Cross-Sectional Studies
  • Female
  • Humans
  • Male
  • Middle Aged
  • Primary Health Care / economics*
  • Socioeconomic Factors
  • Surveys and Questionnaires
  • Switzerland
  • Young Adult

Grants and funding

The study was sponsored by the Department of Ambulatory Care and Community Medicine, University of Lausanne, Switzerland. The authors received grants from the following institutions: the Swiss Academy of Medical Science, the Department of Social Action and Health of the Canton of Vaud, and the Faculty of Biology and Medicine of the University of Lausanne. PB is supported by a Swiss National Science Founding grant (SNF 32 00 3B_13 57 62). IG is supported by a Swiss National Science Foundation grant (SNF 33CM30-124087/1). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.