The frequency with which patients in the Netherlands request a specific intervention during visits with their primary care providers has increased during the past 30 years, as has physicians’ compliance with these requests, new data show. The requests also appear to influence the likelihood of a final diagnosis.
Using data from a Dutch primary healthcare registration network that reflects all encounters between general practitioners (GPs) and patients during three 10-year periods (1985 – 1994, 1995 – 2004, and 2005 – 2014), Jenny van den Broeka from the Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, the Netherlands, and colleagues analyzed documented patient requests for a specific therapeutic or diagnostic intervention. The objective was to determine whether the frequency of such requests has changed over time, how often providers complied with the requests, and the influence of the request on the subsequent diagnostic process.
“We found a significant increase for most requests over time,” the authors report in an article published online April 26 in Family Practice. For example, patients’ requests for blood tests increased from 11.4 per 1000 patient years in the earliest period to 23 in the most recent period. Similarly, requests for urine test increased (from 1.8 to 48.4 per 1000 patient years), as did requests for radiology/imaging (from 1.8 to 4.3), for a medication prescription (from 48.1 to 58.9), and for a referral to specialty care (from 10.1 to 16.2).
The only decrease in requests over time was for referral to another primary care provider. After an initial increase from 5.7 to 14.6 requests per 1000 patient years in the first 2 decades, the rate dropped to 10.1 in the third decade. The authors hypothesize that the decrease could be related to patients’ increased financial risk in health insurance, as well as the fact that referral letters from GPs are no longer necessary for physiotherapy consultations in that country.
The percentage of physician compliance with these requests also increased significantly over time, the authors report. During the 30-year period, compliance with requests rose from 90.3% to 94.1% for blood tests, 88.2% to 100% for urine tests, 70.4% to 84.4% for radiology/imaging, 91.0% to 93.4% for medication, 79.2% to 89.4% for referral to another primary care provider, and 68.8% to 88.5% for referral to specialty care.
In their analysis of the influence patient requests had the subsequent diagnostic process, the investigators identified differences in the final diagnosis between patients who present with a symptom or complaint combined with a request and those who present with the same symptom or complaint without a request.
“Overall, when patients requested an intervention for blood test, radiology, medication prescription and referral to primary or secondary care in addition to a symptom/complaint, a higher likelihood of a final symptom diagnosis was found compared with patients presenting with the same symptom/complaint without a request,” they write. “In contrary, for patients requesting a urine test in addition to a symptom/complaint, a lower likelihood of a final symptom diagnosis was found compared with patients presenting with the same symptom/complaint without this request. Most of these patients were diagnosed with the disease diagnosis cystitis.”
The changes over time in patients’ reasons for primary care encounters and requests for interventions provide insight into the contribution of patients’ behavior in the physician–patient encounter, the authors state. van den Broeka and colleagues comment that the progressively increasing rates of patient requests for interventions are indicative of greater sense of patient empowerment and easy access to medical information through the Internet and television.
With respect to the increase in physician compliance with patient requests, “[m]aybe patients nowadays more frequently ask for interventions that are medically indicated according to the GP, while previously they more frequently asked for interventions that are not indicated according to the GP,” the authors write. “Another explanation might be the increased focus on shared decision making between patient and doctor nowadays.”
Of note, the investigators observed an increase over time in the total number of each of the interventions, except for medication prescription and referral to a different primary care provider. The medication findings may be a consequence of an increased availability of over-the-counter drugs. It’s also possible that the introduction of new clinical practice guidelines for various conditions might influence a provider’s decision to treat vs taking a watch-and-wait approach, the authors state. On the flip side, the increase in diagnostic interventions might reflect physicians’ decreased willingness to take risks.
Finally, patients seeking an intervention were more likely to ultimately be diagnosed with a symptom vs a disease, whereas patients presenting with a symptom without a request for intervention were more likely to be diagnosed with a disease. “Possibly, patients asking for an intervention are more worried about their symptoms, have searched more extensively for information on the Internet or heard in their surroundings that others with certain symptoms got a specific intervention. This may lead to a request for intervention when they present to their GP,” the authors write.
“Given the fact that these patients are more likely to be finally diagnosed with a symptom (the GP could not finally diagnose a clear disease), it is expected that most medical investigations performed because of patients’ request will finally result in no abnormalities.”
Although the findings underscore the clinical relevance of the reason for the encounter and patients’ requests for information, the study did not evaluate whether or not interventions were appropriate, beneficial, or harmful. Awareness of the reason for the encounter, however, “will lead to important information about [patients’] needs, worries, expectations and even results of medical investigations,” the authors write. “The GP should use this information to explore possible underlying concern, anxiety or ignorance and to explain whether or not to be compliant with patient’s request.”
It is unclear whether the findings from this study are generalizable to the US population, according to Leonard Reeves, MD, a family physician and associate dean of the Northwest Clinical Campus of the Medical College of Georgia in Rome, Georgia, and a member of the board of directors of the American Academy of Family Physicians. “The findings are interesting, but I question whether we would see similar patterns in the US,” he said in an interview with Medscape Medical News.
“I do think it is reflective of a change that we are all seeing, that our patients are better informed today than ever. Depending on the population, and it differs among patients in private practice and those in a free clinic, patients are coming in with information they’ve gotten from Google or other sources. I see it as my job to sustain or support that information or give my opinion on it.”
In his own experience, however, the increase in information-empowered patients does not directly translate into more ordering of labs, imaging, or other tests, Reeves explained. “Often when patients come in with an idea of what they need, we use that as a discussion starting point, but my clinical knowledge guides the discussions, and that is the case with most physicians.”
Patients’ increased access to health information has changed clinical practice, however. “The most important thing to read from this study is that the patient population is more engaged in their care decisions than they had been in the past. They expect good two-way communication with their physician, rather than one-way, authoritative dictatorship, and that is a good thing,” Reeves stressed. “Shared decision making is an important part of medical practice today. Patients should feel comfortable enough that they can sit down with their physician and discuss their needs and expectations, and physicians should feel comfortable relating to them in this way and working with them to best meet those needs and expectations.”
The study authors and Reeves have disclosed no relevant financial relationships.
Fam Pract. Published online April 26, 2018. Abstract
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