Do Patient Requests Affect Doctor's Decisions? A Complementary Experimental and Q

患者的要求会影响医生的决定吗？

• 批准号: 7799738
• 负责人: John B McKinlay
• 金额: $ 52.75万
• 依托单位: NEW ENGLAND RESEARCH INSTITUTES, INC.
• 依托单位国家: 美国
• 财政年份: 2009
• 资助国家: 美国
• 起止时间: 2009-04-03 至 2013-03-31
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/7799738
• 关键词: Acetaminophen; Acute; Address; Adherence; Advertising; Affect; Age; Analgesics; Area; Assertiveness; Attitude; Awareness; Behavior; Behavior Therapy; Belief; Caring; Cessation of life; Characteristics; Chronic; Client; Climate; Clinical; Cognitive; Communication; Comorbidity; Complement; Complex; Consult; Contracts; Country; Data; Decision Making; Diagnosis; Diagnostic; Dimensions; Disease; Economics; Educational Intervention; Employee; Employment; Environment; Ethnic Origin; European Union; Face; Feeling; Female; Fright; Gender; Generations; Goals; Gold; Grant; Group Practice; Guidelines; Health; Health Care Costs; Health Personnel; Health Policy; Health system; Healthcare; Healthcare Systems; High Prevalence; Iatrogenesis; Incentives; Influentials; Instruction; Internet; Knee Osteoarthritis; Knowledge; Legal; Link; Litigation; Measurement; Measures; Medical; Medical Errors; Medical center; Minority; Modeling; Motivation; NIH Program Announcements; Opioid; Organizational Decision Making; Ownership; Oxycodone; Pain; Pain Research; Pain management; Patients; Pattern; Perception; Percocet; Performance; Pharmaceutical Preparations; Pharmacologic Substance; Physicians; Polypharmacy; Population; Prevalence; Primary Care Physician; Primary Health Care; Printing; Process; Productivity; Provider; Public Assistance; Public Health; Published Comment; Qualitative Research; Quality of Care; Questionnaires; Race; Recommendation; Reporting; Research; Research Methodology; Risk Factors; Sciatica; Sex Characteristics; Signs and Symptoms; Social support; Specialist; Speed; Suggestion; System; Techniques; Television; Testing; Time; Variant; Woman; Work; base; care seeking; chronic pain; clinical decision-making; clinical practice; cost; demographics; design; direct to consumer advertising; empowered; ethnic minority population; expectation; experience; health care service utilization; health disparity; health literacy; improved; older patient; patient safety; policy implication; pressure; public health relevance; research study; risk perception; sound; study characteristics; success; theories; therapy design; trait

DESCRIPTION (provided by applicant): The U.S. healthcare environment has changed dramatically in the last several decades. Patients are increasingly knowledge-empowered (through internet access) and "activated" (through direct advertising) to seek care from physicians who are increasingly salaried employees in large medical settings (adhering to organizational priorities). "Activated patients" often suggest specific diagnoses to their primary care physicians. Some 30 percent now request specific medications (discovered on television or by internet searches) of which 40 percent receive the requested prescription. Using complementary research methods (factorial experimentation and rigorous qualitative research) we propose to: a) describe how different primary care physicians respond to specific prescription requests from different patients (factorial experiment); and b) explain the reasons why they do so ("think aloud" qualitative techniques). Within a single, cost-efficient study, we propose two experiments focusing on common medical conditions (sciatica and osteoarthritis of the knee) which generate high levels of healthcare utilization, prescribing and costs, to address the following specific aims: 1. To estimate the independent influence of patient attributes on a physician's compliance with a request for a pain medication. Is a request from certain patients more likely to be successful? 2. To estimate the independent influence of provider characteristics on the diagnosis and management of the two pain conditions presented. Are certain physicians more likely to accede to a patient's request? 3. To understand the influence of healthcare system or organizational factors on prescribing and management. Does the size, ownership, practice setting or practice culture influence decisions? 4. A complementary qualitative component will identify the underlying cognitive reasoning processes that explain the observed variability in decisions uncovered by the experimental component of the study. Our findings will have implications for everyday clinical practice, healthcare policy and educational interventions designed to improve the quality of decision making. First, variability in the quality of care provided by primary care physicians for commonly presented pain is of widespread national concern. Second, the influence of patient requests on provider behavior remains poorly understood, but is likely to increase in the U.S. and elsewhere (DTCA of pharmaceuticals is about to be introduced throughout the countries of the European Union). Third, polypharmacy (especially pain medications) is of increasing concern in the US, particularly among older patients with multiple co-morbidities who often consult a range of specialists in addition to primary care providers. Fourth, moving from the description of healthcare variations (how?) to explanation of their cognitive origins (why?) marks a new direction in clinical decision making research and is a necessary pre-requisite for educational interventions. Public Health Relevance: We propose to use a factorial experiment to understand Clinical Decision Making (CDM) when activated patients make requests for a specific pain medication. The implications for a continual and rapid increase of direct to consumer advertising (by Internet, TV, and print), broadening health disparities in chronic pain management, and growing prevalence of chronic pain has significant health policy implications. This study aims to disentangle the patient (gender, race, SES) and physician factors (experience and gender) related to chronic pain management and opioid use, and underlying cognitive reasoning that produce the decisions we observe.

描述（由申请人提供）：在过去的几十年里，美国的医疗保健环境发生了巨大变化。患者越来越多地获得知识授权（通过互联网接入）和“激活”（通过直接广告），以寻求医生的护理，这些医生越来越多地成为大型医疗机构的薪水雇员（坚持组织优先事项）。“激活的病人”经常向他们的初级保健医生建议具体的诊断。大约30%的人现在要求特定的药物（通过电视或互联网搜索发现），其中40%的人收到了所要求的处方。使用互补的研究方法（析因实验和严格的定性研究），我们建议：a）描述不同的初级保健医生如何应对不同患者的特定处方请求（析因实验）;和B）解释他们这样做的原因（“大声思考”定性技术）。在一个单一的，具有成本效益的研究中，我们提出了两个实验，重点是常见的医疗条件（坐骨神经痛和膝关节骨关节炎），产生高水平的医疗保健利用率，处方和成本，以解决以下具体目标：1。估计患者属性对医生依从止痛药要求的独立影响。某些患者的请求是否更有可能成功？2.评估提供者特征对两种疼痛状况的诊断和管理的独立影响。某些医生更有可能答应病人的要求吗？3.了解医疗系统或组织因素对处方和管理的影响。规模、所有权、实践环境或实践文化是否影响决策？4.一个补充的定性组成部分将确定潜在的认知推理过程，解释观察到的变化，在决策发现的实验组成部分的研究。我们的研究结果将对日常临床实践、医疗保健政策和旨在提高决策质量的教育干预措施产生影响。首先，初级保健医生为常见疼痛提供的护理质量的可变性是全国普遍关注的问题。其次，患者请求对提供者行为的影响仍然知之甚少，但在美国和其他地方可能会增加（药品DTCA即将在欧盟各国引入）。第三，在美国，多种药物（特别是止痛药）越来越受到关注，特别是在患有多种合并症的老年患者中，除了初级保健提供者外，他们还经常咨询一系列专家。第四，从医疗保健变化的描述（如何？）解释他们的认知起源（为什么？）标志着临床决策研究的新方向，是教育干预的必要前提。公共卫生相关性：我们建议使用析因实验，以了解临床决策（CDM）时，激活的患者提出要求，为特定的止痛药。直接面向消费者的广告（通过互联网、电视和印刷品）的持续快速增长、慢性疼痛管理中健康差距的扩大以及慢性疼痛患病率的增加具有重要的卫生政策意义。本研究旨在理清与慢性疼痛管理和阿片类药物使用相关的患者（性别，种族，SES）和医生因素（经验和性别），以及产生我们观察到的决策的潜在认知推理。