Keerthi Gogineni1, Katherine L Shuman2, Derek Chinn2, Nicole B Gabler3, Ezekiel J Emanuel4. 1. Division of Hematology-Oncology, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia. 2. Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia. 3. Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia. 4. Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia4Department of Health Care Management, The Wharton School, University of Pennsylvania, Philadelphia5Office of the Provost, University of P.
Abstract
IMPORTANCE: Surveyed physicians tend to place responsibility for high medical costs more on "demanding patients" than themselves. However, there are few data about the frequency of demanding patients, clinical appropriateness of their demands, and clinicians' compliance with them. OBJECTIVE: To assess how frequently patients demand or request medical tests or treatments, what types they demand, the clinical appropriateness of their demands, and how frequently clinicians comply. DESIGN, SETTING, AND PARTICIPANTS: Immediately after visits, clinicians--physicians, fellows, nurse practitioners, and physician assistants--were interviewed about whether the patient made a demand or request and their type and appropriateness. Interviews occurred in oncology outpatient facilities at 3 Philadelphia-area hospitals between October 2013 and June 2014. MAIN OUTCOMES AND MEASURES: The 4 main outcomes were (1) frequency of patient demands for medical tests or treatments, (2) the types of tests or treatments demanded, (3) clinicians' assessment of the clinical appropriateness of the demands, and (4) how frequently clinicians complied. RESULTS: There were 5050 patient-clinician encounters involving 3624 patients and 60 clinicians. Overall, of the 5050 encounters, 440 (8.7%) included a patient demand or request for a medical intervention. Clinicians complied with 365 of the clinically appropriate demands (83.0%). In only 50 of the 440 encounters with demands (11.4%) did the patient demand or request clinically inappropriate interventions. Clinicians complied with 7 of these inappropriate demands or requests (14%). Clinicians complied with inappropriate demands or requests in only 0.14% (7 of 5050) of encounters. Of the 440 patient demands, 216 (49.1%) were for imaging studies; 68 (15.5%) were for palliative treatments, excluding chemotherapy or radiation; and 60 (13.6%) were for laboratory tests. In a multivariable model, having lung/head and neck cancer (odds ratio [OR], 1.74; 95% CI, 1.26-2.41), receiving active treatments (OR, 1.40; 95% CI, 1.11-1.77), and a fair- or poor-quality patient-clinician relationship (OR, 2.82; 95% CI, 1.13-7.07) were associated with patients making demands or requests (all P < .01). CONCLUSIONS AND RELEVANCE: Patient demands occur in 8.7% of patient-clinician encounters in the outpatient oncology setting. Clinicians deem most demands or requests as clinically appropriate. Clinically inappropriate demands occur in 1% of encounters, and clinicians comply with very few. At least in oncology, "demanding patients" seem infrequent and may not account for a significant proportion of costs.
IMPORTANCE: Surveyed physicians tend to place responsibility for high medical costs more on "demanding patients" than themselves. However, there are few data about the frequency of demanding patients, clinical appropriateness of their demands, and clinicians' compliance with them. OBJECTIVE: To assess how frequently patients demand or request medical tests or treatments, what types they demand, the clinical appropriateness of their demands, and how frequently clinicians comply. DESIGN, SETTING, AND PARTICIPANTS: Immediately after visits, clinicians--physicians, fellows, nurse practitioners, and physician assistants--were interviewed about whether the patient made a demand or request and their type and appropriateness. Interviews occurred in oncology outpatient facilities at 3 Philadelphia-area hospitals between October 2013 and June 2014. MAIN OUTCOMES AND MEASURES: The 4 main outcomes were (1) frequency of patient demands for medical tests or treatments, (2) the types of tests or treatments demanded, (3) clinicians' assessment of the clinical appropriateness of the demands, and (4) how frequently clinicians complied. RESULTS: There were 5050 patient-clinician encounters involving 3624 patients and 60 clinicians. Overall, of the 5050 encounters, 440 (8.7%) included a patient demand or request for a medical intervention. Clinicians complied with 365 of the clinically appropriate demands (83.0%). In only 50 of the 440 encounters with demands (11.4%) did the patient demand or request clinically inappropriate interventions. Clinicians complied with 7 of these inappropriate demands or requests (14%). Clinicians complied with inappropriate demands or requests in only 0.14% (7 of 5050) of encounters. Of the 440 patient demands, 216 (49.1%) were for imaging studies; 68 (15.5%) were for palliative treatments, excluding chemotherapy or radiation; and 60 (13.6%) were for laboratory tests. In a multivariable model, having lung/head and neck cancer (odds ratio [OR], 1.74; 95% CI, 1.26-2.41), receiving active treatments (OR, 1.40; 95% CI, 1.11-1.77), and a fair- or poor-quality patient-clinician relationship (OR, 2.82; 95% CI, 1.13-7.07) were associated with patients making demands or requests (all P < .01). CONCLUSIONS AND RELEVANCE: Patient demands occur in 8.7% of patient-clinician encounters in the outpatient oncology setting. Clinicians deem most demands or requests as clinically appropriate. Clinically inappropriate demands occur in 1% of encounters, and clinicians comply with very few. At least in oncology, "demanding patients" seem infrequent and may not account for a significant proportion of costs.
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