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Patients' Role in the Use of Radiology Testing for Common Office Practice Complaints
Ira B. Wilson, MD, MSc;
Kim Dukes, MA;
Sheldon Greenfield, MD;
Sherrie Kaplan, MPH, PhD;
Bruce Hillman, MD
Arch Intern Med. 2001;161:256-263.
Background Radiological studies are an important component of ambulatory medical
costs, and guidelines often focus on their appropriate use. However, little
is known about the correlates of the use of those services, particularly the
influence of patients' preferences on physicians' utilization decisions.
Objectives To study patients presenting for outpatient treatment of respiratory
problems and low back pain, and to examine the magnitude of the effect of
the patients' perceived need for radiological studies (radiology preference
score) on use of those services.
Design Cross-sectional survey.
Setting Office practices of generalist physicians in predominantly rural areas
of 8 states.
Participants A total of 52 generalist physicians agreed to enroll consecutive Medicare-eligible
patients making office visits for respiratory problems or low back pain. Of
1785 eligible patients invited to participate, 132 (7%) refused and 1137 (69%)
of 1653 returned questionnaires.
Measurements Radiology utilization rates (plain film, computed tomographic scan,
or magnetic resonance image scan) were determined by patient self-report.
To assess perceived need for radiological studies, we asked patients how necessary
they believed an x-ray film was in the evaluation of 4 common complaints (respiratory
problems, low back pain, knee pain, and knee swelling). A summary radiology
preference score was created from 3 of the 4 items, excluding the item referring
to the patients' index complaint.
Results Six hundred fifteen respiratory and 522 low back pain patients were
enrolled; mean ages were 69 and 64 years, respectively. Radiology utilization
rates were 37% for respiratory and 26% for low back pain patients. In multiple
logistic regression models, for respiratory patients radiology utilization
was related significantly to the radiology preference score (odds ratio [OR]
for fourth quartile compared with first quartile, 1.94; 95% confidence interval
[CI], 1.11-3.37; P = .02), to having a physician
who owned radiology equipment (OR, 1.81; 95% CI, 1.23-2.66; P = .002), and current smoking (OR, 1.58; 95% CI, 1.04-2.41; P = .03). For low back pain patients, radiology utilization
was significantly related to the radiology preference score (OR for fourth
compared with first quartile, 2.55; 95% CI, 1.29-5.06; P = .007), bothersomeness of the pain (OR for fourth compared with
first quartile, 3.74; 95% CI, 1.74-8.04; P<.001),
and a diagnosis of osteoporosis (OR, 1.67; 95% CI, 1.01-2.75; P = .04).
Conclusions Patients' perceived need for radiological studies was significantly
associated with use of those services for outpatients with respiratory problems
and low back pain. These findings suggest that patients communicate their
wishes to physicians, either directly or indirectly, regarding services they
think are necessary. Differences in physicians' adherence to guidelines regarding
radiology utilization may in part reflect variations in patients' perceived
need for those services. Efforts to educate patients about when radiological
studies are medically indicated may be an important complement to practice
guidelines or other utilization-related financial incentives.
From the the Division of Clinical Care Research (Dr Wilson), the Primary
Care Outcomes Research Institute (Drs Greenfield and Kaplan), Department of
Medicine, New England Medical Center and Tufts University School of Medicine,
Boston, Mass; the Department of Radiology, University of Virginia, Charlottesville
(Dr Hillman); and DM-Stat, Inc, Medford, Mass (Ms Dukes).
Reprints and corresponding author: Ira B. Wilson, MD, MSc, New England
Medical Center, Box 345, 750 Washington St, Boston, MA 02111 (e-mail: IWilson{at}Lifespan.org).
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