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Direct Observation of Requests for Clinical Services in Office Practice
What Do Patients Want and Do They Get It?
Richard L. Kravitz, MD, MSPH;
Robert A. Bell, PhD;
Rahman Azari, PhD;
Steven Kelly-Reif, MD;
Edward Krupat, PhD;
David H. Thom, MD, PhD
Arch Intern Med. 2003;163:1673-1681.
Background Requests can influence the conduct and content of the medical visit. However, little is known about the nature, frequency, and impact of such requests. We performed this study to ascertain the prevalence, antecedents, and consequences of patients' requests for clinical services in ambulatory practice.
Methods This observational study combined patient and physician surveys with audiotaping of 559 visits to 45 physicians in 2 health care systems between January and November 1999. All patients had a new problem or significant health concern. Main outcome measures included prevalence of 8 categories of requests for physician action; odds of patients' requesting tests, referrals, or new prescriptions; odds of physicians' ordering diagnostic tests, making specialty referrals, or writing new prescriptions; patient satisfaction; and physicians' perceptions of the visit.
Results The 559 patients made 545 audiocoded requests for physician action; 23% requested at least 1 diagnostic test, specialty referral, or new prescription medication. Requests for diagnostic tests were more common among new patients (P<.001). Requests for any clinical service were more common among patients experiencing greater health-related distress (P<.05) and less common among patients of cardiologists (P<.001). After adjusting for predisposing, need, and contextual factors, referral requests were associated with higher odds of receiving specialty referrals (adjusted odds ratio [AOR], 4.1; 95% confidence interval [CI], 1.6-10.7) and prescription requests were associated with higher odds of receiving new prescription medications (AOR, 2.8; 95% CI, 1.2-6.3). Physicians reported that visits during which patients requested diagnostic tests were more demanding than visits in which no such requests were made (P = .02).
Conclusions Though more common in primary care than in cardiology, patients' requests for clinical services are both pervasive and influential. The results support placing greater emphasis on understanding and addressing the patient's role in determining health care utilization.
From the Center for Health Services Research in Primary Care, University of California, Davis, Sacramento (Dr Kravitz); Department of Communication and Center for Health Services Research in Primary Care (Dr Bell); Department of Statistics and Center for Health Services Research in Primary Care (Dr Azari); Kaiser-Permanente Medical Group, Sacramento (Dr Kelly-Reif); School of Arts and Sciences, Massachusetts College of Pharmacy and Health Sciences, Boston (Dr Krupat); and Department of Family and Community Medicine, University of California, San Francisco (Dr Thom).
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