Author: Anna Azvolinsky, PhD
A new study suggests that cancer patients tend not to request unnecessary and sometimes costly tests or treatments. Of the 5,050 interactions between a clinician and patient analyzed, only 1% resulted in a patient request for a clinically unnecessary or inappropriate test or therapy. Clinicians complied with only 7 of 50 requests (14%).
The study goes against a common assumption that the high cost of healthcare in the United States is partly due to extra or unnecessary treatments and analyses done as a result of patients’ requests.
The results of the study were published in JAMA Oncology.
Researcher Ezekiel J. Emanuel, MD, PhD, of the department of medical ethics and health policy at the Perelman School of Medicine of the University of Pennsylvania, and colleagues analyzed a total of 5,050 outpatient interactions among 60 clinicians and 3,624 patients that occurred between October 2013 and June 2014 at three Philadelphia-area hospitals. The 60 clinicians—34 oncologists, 11 oncology fellows, and 15 nurse practitioners and physician assistants—were interviewed by trained research assistants on each patient-clinician encounter.
“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 Emanuel in a statement. “However, we found, contrary to expectations, that patient demands are low and cannot be a key driver of increasing healthcare costs.”
Most of the patients in the study were women (58.7%), and of the 5,050 encounters, 57.5% were between a clinician and a female patient. More than 50% of patients were between 55 and 74 years of age; 69.4% were white. More than half of the patients had private insurance (56.3%), while 40.6% had Medicare. The most common cancer types diagnosed among the patients were hematologic malignancies (25.9%). The next most common cancer type was gastrointestinal cancer.
Of the 5,050 encounters, 8.7% (440) included a request for treatment, test, or imaging by the patient. Clinicians complied with 83% (365) of these requests. Of the 440 requests, clinicians considered 11.4% of them to be inappropriate or unnecessary.
“At least in oncology, ‘demanding patients’ seem infrequent and may not account for a significant proportion of costs,” concluded the authors.
Of the 440 demands, 49.1% were requests for imaging, 15.5% were for palliative treatments, and 13.6% were for laboratory testing. A lung or head and neck cancer diagnosis, a fair- or poor-quality patient-clinician relationship, and active treatment by the patient were all factors associated with patient requests (all P < .01).
The United States spent $3 trillion on healthcare in 2014; at least one prior analysis of physicians’ sentiments showed that they believe that the availability of information on the Internet and patient-directed marketing stimulate patients to request novel and expensive tests and therapies. Still, there is a dearth of data on whether these physician claims are substantiated—both the frequency of such requests and whether or how often clinicians catered to them.
“We observed very few patient demands for inappropriate treatments, and it was even rarer that a physician complied with the demand,” said study author Keerthi Gogineni, MD, MSHP, of Winship Cancer Institute of Emory University in Atlanta, in a statement. “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.”
Whether the results can be generalized to inpatient interactions, other US geographies, and other practices outside of oncology is not clear. Most of the patients had private insurance; therefore, other studies should analyze whether the results are applicable to a larger Medicare and less affluent population.
In an accompanying editorial, Anthony L. Back, MD, of the Seattle Cancer Care Alliance and Fred Hutchinson Cancer Research Center at the University of Washington in Seattle, acknowledged what he called the “myth of the demanding patient.”
“The real point of the study, however, is this: we have to stop blaming patients for being demanding. In reality, it is hardly happening. The myth of the demanding patient is more about our own responses and how lackluster communication skills can contribute to difficult situations that stick in our throats and our memories. And when we have calmed down enough to look up, we see that what is really happening between patients and physicians these days is something quite different,” wrote Back. “It is possible that what the study by Gogineni et al 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.”