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Frequency of patient demands for unnecessary oncology tests overstated
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The conventional wisdom that demanding patients often push for inappropriate or unnecessary tests or treatments may be misguided, according to study results.
Physicians often attribute unnecessary testing or care — and, in turn, higher medical costs — to patient requests they feel obligated to fulfill to protect their relationship, make their practice flourish and maintain a level of patient satisfaction, according to study background.
Ezekiel Emanuel
“Doctors think that requests from patients have a key role in driving health care costs,” Ezekiel Emanuel, MD, PhD, Diane v.S. Levy and Robert M. Levy professor, and chair of the department of medical ethics and health policy at the University of Pennsylvania, told HemOnc Today. “But there was no data in the literature that I could find about how frequently patients demand. I thought we ought to find out how often this is happening.”
Emanuel and colleagues conducted a multicenter study to determine the frequency of patient demands for tests or treatment. The researchers also evaluated the types of tests or treatment demanded, the appropriateness of those demands based on clinician assessment, and the frequency with which clinicians complied with their patients’ requests.
The investigators analyzed 5,050 patient–clinician encounters among 3,624 unique patients at oncology practices at three Philadelphia hospitals. All encounters occurred between October 2013 and June 2014.
Researchers also interviewed 60 clinicians — 34 oncologists, 11 oncology fellows, and 15 nurse practitioners and physician assistants.
The clinicians who participated in the study used a Likert scale to rank the appropriateness of patient requests. Those scored between 8 and 10 were considered appropriate. Those scored between 4 and 7 were considered equivocal. Those scored between 1 and 3 were considered inappropriate.
Clinicians also graded what their relationship with each patient was like, characterizing them as excellent (65.5%), very good (17.7%), good (4.4%) and fair/poor (0.6%). The remaining 11.8% either were new patients, or the clinician did not evaluate the relationship.
Patients made demands in 8.7% of the encounters. Of those requests, clinicians rated 71.8% as clinically appropriate, 16.8% as equivocal and 11.4% as clinically inappropriate.
Taking the entire study population into account, 6.3% of the patients demanded a clinically appropriate test, treatment or other medical intervention, and only 1% demanded a clinically inappropriate test, treatment or intervention.
“That result was surprising to us,” Emanuel said. “This doesn’t correspond to what doctors think they are experiencing.”
Most patient demands were for imaging (49.1%), palliative treatment (15.5%) or lab testing (13.6%).
Among those that were deemed clinically inappropriate, 36% were for imaging, 18% were for chemosensitivity assays, 18% were for the administration of unnecessary IV fluids, 16% were for lab testing, 4% were for proton beam therapy and 2% were for palliative care.
Clinicians complied with 83% of the patient requests overall, including 98.1% of clinically appropriate demands and 64.9% of equivocal demands.
Clinicians complied with seven of 50 (0.14%) clinically inappropriate requests.
Emanuel and his colleagues were surprised they observed no association between income level and demand for care.
“The inevitable questions are: Is Philadelphia different? Is oncology different? Do you get more requests from primary care?” Emanuel said. “I believe that if we [were to] do this in a richer environment, like Manhattan or Beverly Hills, it’s not going to be much different. We sent this manuscript to a colleague who is a pulmonary care doctor and he said, ‘Of course oncology patients don’t ask for everything, they’re already getting everything. There’s nothing more to ask for.’ I don’t think that’s the case.”
In fact, conventional wisdom suggests the rate of inappropriate requests from patients should be even higher among patients with cancer, Emanuel said.
“If you are going to see this type of phenomenon, it’s going to be much more likely in oncology because the stakes are so high,” he said. “It’s life or death. Pneumonia? That’s not life or death. Upset stomach? That’s not life or death. If you don’t see it in oncology, it’s unlikely to be seen in other parts of medicine at a higher rate. If we didn’t see it, I’m skeptical that it’ll be found in other [settings]. But that’s an empirical question and I love to collect data, so we ought to do that study, too,” Emanuel said.
Anthony L. Back, MD, professor at the University of Washington and Fred Hutchinson Cancer Research Center, offered his own hypothesis in an accompanying editorial.
“These findings say more about our own clinical sensibilities than what they reveal about our patients,” Back wrote. “Although demanding patients are not common, they often figure prominently in our memories because our cognitive biases tend to spot outliers.”
A “tectonic shift in the dynamics between patients and physicians” related to cancer is underway, as patients in the Internet age have started to think about their treatment preferences and decision-making before they ever visit with an oncologist, Back said.
“What patients value from physicians is being guided to the information they need and want; being given that information at a pace they can absorb; having access to the physician’s clinical experience; and feeling that the physician recognizes their situation, their individuality and their humanness,” Back wrote. “It is possible that what [this study] documents is a point in the evolution of the patient–physician relationship when both sides recognize that the complexity of cancer care belies a simple fix. Perhaps this ‘negative’ study is pointing to an important truth: that we need to redirect our attention from the myths that are distracting us.” – by Anthony SanFilippo
Disclosure: The researchers report no relevant financial disclosures.
Ezekiel Emanuel, MD, PhD, can be reached at Department of Health Care Management, The Wharton School, University of Pennsylvania, 122 College Hall, Philadelphia, PA 19104-6303; email: vp-global@upenn.edu.
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