Direct observation of requests for clinical services in office practice what do patients want and do they get it?

Richard L Kravitz, Robert A Bell, Rahman Azari, Steven Kelly-Reif, Edward Krupat, David H. Thom

Research output: Contribution to journalArticle

87 Citations (Scopus)

Abstract

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.

Original languageEnglish (US)
Pages (from-to)1673-1681
Number of pages9
JournalArchives of Internal Medicine
Volume163
Issue number14
DOIs
StatePublished - Jul 28 2003

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Observation
Physicians
Prescriptions
Referral and Consultation
Routine Diagnostic Tests
Odds Ratio
Patient Acceptance of Health Care
Confidence Intervals
Health
Cardiology
Patient Satisfaction
Observational Studies
Primary Health Care
Outcome Assessment (Health Care)
Delivery of Health Care

ASJC Scopus subject areas

  • Internal Medicine

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Direct observation of requests for clinical services in office practice what do patients want and do they get it? / Kravitz, Richard L; Bell, Robert A; Azari, Rahman; Kelly-Reif, Steven; Krupat, Edward; Thom, David H.

In: Archives of Internal Medicine, Vol. 163, No. 14, 28.07.2003, p. 1673-1681.

Research output: Contribution to journalArticle

Kravitz, Richard L ; Bell, Robert A ; Azari, Rahman ; Kelly-Reif, Steven ; Krupat, Edward ; Thom, David H. / Direct observation of requests for clinical services in office practice what do patients want and do they get it?. In: Archives of Internal Medicine. 2003 ; Vol. 163, No. 14. pp. 1673-1681.
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abstract = "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.",
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