Patient Request/Demand for Clinically Inappropriate Intervention Uncommon in Outpatient Setting
Increases in medical costs are often attributed to ‘demanding’ patients. In a study reported in JAMA Oncology, Gogineni et al found that approximately 9% of patient encounters in outpatient oncology clinics included patient demands or requests for tests or treatment, that the majority of such requests were clinically appropriate, and that the majority of clinically appropriate requests were met. Clinically inappropriate demands/requests were made in approximately 1% of encounters and usually were not met.
Study Details
In the study, physicians, fellows, nurse practitioners, and physician assistants in oncology outpatient clinics at three Philadelphia area hospitals were interviewed immediately after patient visits about whether the patient made a demand or request and the type and appropriateness of the request. Interviews were conducted between October 2013 and June 2014.
In total, there were 5,050 patient-clinician encounters involving 3,624 patients and 60 clinicians. Most patients were female (59%) and white (69%); 42% were aged > 65 years. The most common cancers were hematologic (26%), gastrointestinal (20%), breast (18.5%), and lung/head and neck (13%); 64% had stage I, II, or III disease. Among the clinicians, 50% were female and 88% were white; clinicians evaluated their relationship with the patient as excellent in 66% of cases, very good in 18%, good in 4%, and fair or poor in 0.6%.
Frequency of Demands/Requests
Among the 5,050 encounters, 440 (8.7%) included a patient demand or request for a medical intervention. Clinicians rated 316 of them (71.8%) as clinically appropriate, 50 (11.4%) as clinically inappropriate, and 74 (16.8%) as equivocal. Among all 5,050 encounters, requests were considered appropriate in 6.3% of encounters, equivocal in 1.5%, and inappropriate in 1.0%. Overall, clinicians complied with 365 (83%) of the 440 requests, including 310 (98%) of 316 appropriate requests, 48 (65%) of 74 equivocal requests, and 7 (14%) of 50 inappropriate requests; thus, clinicians complied with inappropriate demands/requests in 0.14% of encounters.
Of the 440 patient demands, 49% were for imaging studies, 15% were for palliative treatments excluding chemotherapy and radiation therapy, and 14% were for laboratory tests. On multivariate analysis, lung/head and neck cancer (odds ratio [OR] = 1.74), receiving active treatments (OR = 1.40), and fair or poor patient-clinician relationship (OR = 2.82) were significantly associated with patients’ making demands or requests (all P < .01).
The investigators concluded: “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.”
Ezekiel J. Emanuel, MD, PhD, of the University of Pennsylvania, is the corresponding author of the JAMA Oncology article.
The authors reported no conflicts of interest.
The content in this post has not been reviewed by the American Society of Clinical Oncology, Inc. (ASCO®) and does not necessarily reflect the ideas and opinions of ASCO®.
