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Importance of patient pressure and perceived pressure and perceived medical need for investigations, referral, and prescribing in primary care: nested observational study

Little, Paul, Dorward, Martina, Warner, Greg, Stephens, Katharine, Senior, Jane and Moore, Michael (2004) Importance of patient pressure and perceived pressure and perceived medical need for investigations, referral, and prescribing in primary care: nested observational study BMJ, 328, (7437), pp. 444-446. (doi:10.1136/bmj.38013.644086.7C).

Record type: Article


Objective: To assess how pressures from patients on doctors in the consultation contribute to referral and investigation.
Design: Observational study nested within a randomised controlled trial.
Setting: Five general practices in three settings in the United Kingdom.
Participants: 847 consecutive patients, aged 16-80 years.
Main outcomes measures: Patient preferences and doctors' perception of patient pressure and medical need.
Results: Perceived medical need was the strongest independent predictor of all behaviours and confounded all other predictors. The doctors thought, however, there was no or only a slight indication for medical need among a significant minority of those who were examined (89/580, 15%), received a prescription (74/394, 19%), or were referred (27/125, 22%) and almost half of those investigated (99/216, 46%). After controlling for patient preference, medical need, and clustering by doctor, doctors' perceptions of patient pressure were strongly associated with prescribing (adjusted odds ratio 2.87, 95% confidence interval 1.16 to 7.08) and even more strongly associated with examination (4.38, 1.24 to 15.5), referral (10.72, 2.08 to 55.3), and investigation (3.18, 1.31 to 7.70). In all cases, doctors' perception of patient pressure was a stronger predictor than patients' preferences. Controlling for randomisation group, mean consultation time, or patient variables did not alter estimates or inferences.
Conclusions: Doctors' behaviour in the consultation is most strongly associated with perceived medical need of the patient, which strongly confounds other predictors. However, a significant minority of examining, prescribing, and referral, and almost half of investigations, are still thought by the doctor to be slightly needed or not needed at all, and perceived patient pressure is a strong independent predictor of all doctor behaviours. To limit unnecessary resource use and iatrogenesis, when management decisions are not thought to be medically needed, doctors need to directly ask patients about their expectations.

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Published date: 2004
Additional Information: Primary Care


Local EPrints ID: 24411
ISSN: 0959-8138
PURE UUID: dda267a6-3571-4bec-8a21-43254cf7e0e4
ORCID for Michael Moore: ORCID iD

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Date deposited: 30 Mar 2006
Last modified: 17 Jul 2017 16:13

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Author: Paul Little
Author: Martina Dorward
Author: Greg Warner
Author: Katharine Stephens
Author: Jane Senior
Author: Michael Moore ORCID iD

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