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: 8248282
• 负责人: John B McKinlay
• 金额: $ 52.06万
• 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 2014-03-31
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/8248282
• 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）：过去几十年来，美国的医疗保健环境发生了巨大变化。患者越来越获得知识授权（通过互联网访问）并“主动”（通过直接广告）向医生寻求治疗，而医生是大型医疗机构中越来越多的受薪员工（遵守组织优先事项）。 “活跃的患者”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。我们建议使用补充研究方法（因子实验和严格的定性研究）：a）描述不同的初级保健医生如何响应不同患者的特定处方请求（因子实验）； b) 解释他们这样做的原因（“大声思考”定性技术）。在一项具有成本效益的研究中，我们提出了两项​​针对常见医疗状况（坐骨神经痛和膝骨关节炎）的实验，这些疾病产生了高水平的医疗保健利用率、处方和成本，以实现以下具体目标： 1. 估计患者属性对医生对止痛药要求的依从性的独立影响。某些患者的请求是否更有可能成功？ 2. 评估提供者特征对所提出的两种疼痛状况的诊断和管理的独立影响。某些医生是否更有可能满足患者的要求？ 3. 了解医疗保健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会影响决策？ 4. 补充性的定性成分将识别潜在的认知推理过程，解释研究实验成分所揭示的决策中观察到的变异性。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，初级保健医生针对常见疼痛提供的护理质量的差异引起了全国的广泛关注。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（欧盟国家即将推出药品 DTCA）。第三，多重用药（尤其是止痛药）在美国越来越受到关注，特别是对于患有多种合并症的老年患者来说，除了初级保健提供者之外，他们还经常咨询一系列专家。第四，从描述医疗保健变化（如何？）转向解释其认知起源（为什么？）标志着临床决策研究的新方向，也是教育干预的必要先决条件。公共卫生相关性：当活跃的患者提出特定止痛药的请求时，我们建议使用析因实验来了解临床决策 (CDM)。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、慢性疼痛管理方面健康差距的扩大以及慢性疼痛患病率的不断上升，都对卫生政策产生了重大影响。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、社会经济地位）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。

项目成果

Effects of patient medication requests on physician prescribing behavior: results of a factorial experiment.

• DOI: 10.1097/mlr.0000000000000096
• 发表时间: 2014-04
• 期刊: Medical care
• 影响因子: 3
• 作者: McKinlay JB;Trachtenberg F;Marceau LD;Katz JN;Fischer MA
• 通讯作者: Fischer MA