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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

Importance of patient pressure and perceived pressure and perceived medical need for investigations, referral, and prescribing in primary care: nested observational study
Importance of patient pressure and perceived pressure and perceived medical need for investigations, referral, and prescribing in primary care: nested observational study
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.
0959-8138
444-446
Little, Paul
1bf2d1f7-200c-47a5-ab16-fe5a8756a777
Dorward, Martina
ede98eab-1027-4a21-a38c-3bccb7c71e06
Warner, Greg
72005519-1aa0-42da-b370-7ebd99792539
Stephens, Katharine
03f444ea-c86c-43ba-99af-09ac90a8de09
Senior, Jane
466f62e7-dce3-4e6c-a73d-53357d05f550
Moore, Michael
1be81dad-7120-45f0-bbed-f3b0cc0cfe99
Little, Paul
1bf2d1f7-200c-47a5-ab16-fe5a8756a777
Dorward, Martina
ede98eab-1027-4a21-a38c-3bccb7c71e06
Warner, Greg
72005519-1aa0-42da-b370-7ebd99792539
Stephens, Katharine
03f444ea-c86c-43ba-99af-09ac90a8de09
Senior, Jane
466f62e7-dce3-4e6c-a73d-53357d05f550
Moore, Michael
1be81dad-7120-45f0-bbed-f3b0cc0cfe99

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), 444-446. (doi:10.1136/bmj.38013.644086.7C).

Record type: Article

Abstract

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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More information

Published date: 2004
Additional Information: Primary Care

Identifiers

Local EPrints ID: 24411
URI: http://eprints.soton.ac.uk/id/eprint/24411
ISSN: 0959-8138
PURE UUID: dda267a6-3571-4bec-8a21-43254cf7e0e4
ORCID for Michael Moore: ORCID iD orcid.org/0000-0002-5127-4509

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Date deposited: 30 Mar 2006
Last modified: 09 Jan 2022 03:17

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Contributors

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

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