Patient demands not a factor in inappropriate tests, treatments

CHICAGO — Patients rarely demanded inappropriate tests and treatments, and when they did providers were unlikely to fulfill those requests, according to study results presented at the ASCO Annual Meeting.

“There is this perception that part of the reason we’re ordering inappropriate treatment and tests that come with high costs and low value is that it’s being driven by patients’ expectations and requests,” study investigator Keerthi Gogineni, MD, MSHP, instructor in the division of hematology-oncology of the Perelman Center for Advanced Medicine at the Hospital of the University of Pennsylvania and the Abramson Cancer Center, said in an interview. “But the truth was, we found a really low frequency of patients actually asking for things, and most of the time they were actually appropriate requests.”

Gogineni and colleagues conducted a survey among 54 oncologists and nurse practitioners from two academic cancer centers who had seen a combined 3,827 patients. The mean age of patients was 60 years, and 72% were non-Hispanic white. Most patients had stage I to III disease (57%), were actively receiving treatment (70%) and were seeing their provider for a follow-up visit (91%).

Overall, only 9% of patients made a request or a demand of their provider. The most common requests included those for imaging (50.3%), blood work (11.9%) or palliative care (10.5%).

The providers then were asked to score the demands and requests of patients as inappropriate, equivocal or appropriate.

Those surveyed deemed 82.6% of the requests appropriate, whereas 11.9% were considered inappropriate. In most cases the clinician complied with the patient’s request (84%); however, only 0.18% of tests or treatments that were ordered due to a patient’s request were considered inappropriate.

Inappropriate requests were 9 times more likely to originate from patients with early-stage disease undergoing observation vs. those with advanced disease undergoing observation, and patients with late-stage disease undergoing observation were 1.7 times more likely to make an inappropriate demand compared with those receiving treatment.

“That patients who are undergoing observation, as opposed to treatment, are more likely to make inappropriate requests makes sense,” Gogineni said. “We use ordering of tests and treatments as a way to feel like we’re doing something when, in fact, sometimes just having a nuanced conversation about what constitutes evidence-based surveillance is probably more effective to reassure patients.”

Future research should focus on other factors that may contribute to inappropriate tests and treatment, Gogineni said.

“We feel like this dismisses this myth that patients are the reason that we’re driven to order those inappropriate tests,” Gogineni said. “I don’t doubt that we’re still ordering a high number of inappropriate tests or treatment, but I don’t think there’s a patient-driven factor.”

For more information:

Gogineni K. Abstract #6530. Presented at: ASCO Annual Meeting; May 30-June 3, 2014; Chicago.

Disclosure: The researchers report no relevant financial disclosures.