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

描述(由申请人提供)：在过去的几十年里，美国的医疗环境发生了巨大的变化。患者的知识能力越来越强(通过互联网接入)，并且(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(遵循组织的优先事项)。“活跃患者”通常会向他们的初级保健医生建议具体的诊断。约30%的人现在要求服用特定的药物(在电视或互联网搜索中发现)，其中40%的人收到了要求的处方。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对不同患者的特定处方请求作出反应(析因实验)；以及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单一研究中，我们提出了两个实验，聚焦于产生高水平医疗利用、处方和成本的常见医疗条件(坐骨神经痛和膝骨性关节炎)，以解决以下具体目标：1.估计患者属性对医生对止痛药请求的依从性的独立影响。某些患者的请求更有可能成功吗？2.评估提供者特征对两种疼痛状况的诊断和处理的独立影响。某些医生是否更愿意接受病人的要求？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会影响决策？4.补充的定性成分将确定潜在的认知推理过程，这些过程解释了研究的实验部分发现的决策的可变性。我们的发现将对日常临床实践、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(药品的DTCA即将在整个欧盟国家引入)。第三，在美国，多药(尤其是止痛药)越来越令人担忧，特别是在患有多种并发症的老年患者中，他们除了咨询初级保健提供者外，还经常咨询一系列专家。第四，从对医疗保健变化的描述转移到(如何？)来解释他们的认知起源(为什么？)标志着临床决策研究的一个新方向，也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来理解临床决策(CDM)，当被激活的患者要求特定的止痛药时。直接面向消费者的广告(通过互联网、电视和印刷)持续快速增加，扩大慢性疼痛管理中的健康差距，以及慢性疼痛日益普遍，这对卫生政策具有重大影响。这项研究的目的是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定的潜在认知推理。

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.