Pennsylvania University. US: Physicians often blame patient demands for contributing to high medical
costs, however, a new study involving more than 5,000 patient-clinician
visits indicates that cancer patients rarely push for unnecessary tests
and treatments from their health care providers.
The study, conducted by Ezekiel Emanuel, MD, PhD and colleagues in the Abramson Cancer Center and the Perelman School of Medicine at the University of Pennsylvania and published in the inaugural issue of JAMA Oncology,
examined a total of 5,050 patient-clinician encounters, and found that
440 (8.7 percent) of those included a patient demand or request for a
medical intervention. Clinicians complied with 365 of the demands they
deemed clinically appropriate. However, of the 50 demands requesting
clinically inappropriate tests or treatments, clinicians only complied
with seven (0.14 percent of the 5,050 encounters).
About half of the requests (49.1 percent) were for imaging studies,
13.6 percent were for laboratory tests such as tumor markers, and 5.2
percent were for genetic tests or chemosensitivity tests. Surprisingly,
15.5 percent of patient demands or requests were for palliative care
interventions, such as pain medications and sleeping aides. Just 3.6
percent of patient demands or requests were for chemotherapy, and less
than one percent for expensive proton beam therapy.
“We decided to look specifically at cancer patients’ demands because
oncology is a setting where there are life-and-death stakes for
patients and the drugs and tests can get very expensive,” said senior
author Emanuel, chair of the department of Medical
Ethics and Health Policy at Penn. “However, we found, contrary to
expectations, that patient demands are low and cannot be a key driver
of increasing health care costs.”
The Penn Medicine team surveyed 60 clinicians — including 34
oncologists, 11 oncology fellows, and 15 nurse practitioners and
physician assistants — immediately after patient encounters at three
Philadelphia Hospitals (The Hospital of the University of Pennsylvania,
Penn Presbyterian Medical Center and Pennsylvania Hospital) between
October 2013 and June 2014. The goals of the interviews were to
determine frequency of patient requests or demands for tests and
treatments, whether those requests were appropriate, whether they were
granted and why.
The study also found that patients who had worse relationships with
their physicians, and those on active therapy, were more likely to
make demands or requests for tests or treatments.
“We observed very few patient demands for inappropriate treatments,
and it was even rarer that a physician complied with the demand,” said
lead author Keerthi Gogineni, MD, MSHP, who was an instructor in Penn’s
Abramson Cancer Center when the study was conducted and is now a
faculty member at Emory University.
“In this age of unregulated consumer medical information on the
Internet, it’s encouraging to see that this hasn’t translated to cancer
patients requesting inappropriate — and often costly — tests and
treatments.”
The other Penn authors include Katherine L. Shuman, MSN, RN, Derek Chinn, BS and Nicole B. Gabler, PhD, MHA. Preliminary results of the study were presented during the annual meeting of the American Society of Clinical Oncology (ASCO) in June 2014.