Importance of patient pressure and perceived pressure and perceived medical need for investigations, referral, and prescribing in primary ca
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《英国医生杂志》
1 Primary Medical Care, Community Clinical Sciences Division, Southampton University, Aldermoor Health Centre, Southampton SO16 5ST, 2 Nightingale Surgery, Romsey SO51 7QN, 3 Three Swans Surgery, Salisbury SP1 1DX
Correspondence to: P Little psl3@soton.ac.uk
Abstract
General practitioners act as the gateway to most prescribing, investigation, and referral. This has enormous implications for the use of resources in secondary care, "medicalisation," and iatrogenesis, particularly if management is unwittingly inappropriate or ineffective.1-6 Investigating and referring also take time—the main resource in primary care and a major determinant of quality of care.7
Doctors' incorrect perceptions of patients' expectations predict prescribing, and, as doctors tend not to elicit patients' expectations or unvoiced agendas, this results in unnecessary prescriptions and poor compliance.8-12 Most quantitative studies have not, however, controlled for perceived medical need: it may be that when this is controlled for there is little impact on doctors' behaviour from perceived patient pressure. Patients' personal characteristics influence referral and investigation, and a questionnaire survey of doctors showed a variety of non-medical factors that influence decisions to investigate.3 13 Yet little work has been done to quantify doctors' perceptions of pressures from patients in consultations which lead to physical examination, further investigation, and referral. Given the importance of appropriate referrals and investigations it cannot simply be extrapolated that all doctor behaviours are the same. We therefore assessed the relative impact of patient pressure and doctors' perception of that pressure on a range of doctor behaviours in the consultation, while assessing and controlling for perceived medical need.
Methods
We recruited fewer patients from doctors with short (< 9 minutes) consultation times (14 patients 30 patients) because we had less time in which to comply with study protocols before the consultation. We obtained information on 45 consecutive patients booked to see doctors with long consultation times (where nearly all eligible patients could be approached): 14 (31%) were excluded (six were receiving treatment for anxiety or depression, four were out of our age range, two were too ill, and two only collected prescriptions). Of the 31 eligible patients, 17 (55%) agreed to participate. They were similar to those who did not agree for age and chronic medical problems. We received all questionnaires completed before the consultation, 418 (76%) of those completed after the consultation, and 612 (96%) completed by the doctors.
The characteristics of the study group were similar to previous national samples for the population attending general practitioners for age and being male, in paid work, and married.16
Patients who failed to complete the post-consultation questionnaire were similar to those who completed the study for worry about problem, feeling unwell, seeing usual doctor, and whether problem was new or ongoing.
Tables 1, 2, 3, 4 show the impact of different pressures predicting each doctor behaviour. The doctors' perception of medical need was the strongest factor for determining behaviour in the consultation and significantly confounded the predictive value of both patient pressure and perceived patient pressure (change in odds ratios > 50%). The doctors thought, however, there was no or only slight medical need among a significant proportion of those examined (89/580, 15%), given a prescription (74/394, 19%), or referred (27/125, 22%) and among almost half of those investigated (99/216, 46%). After perceived medical need was controlled for, perceived patient pressure was an independent predictor of doctors' behaviour for all behaviours, and a stronger predictor than patients' preferences measured before the consultation.
Table 1 Effect of patient pressure on whether doctors prescribed
Table 2 Effect of patient pressure on whether doctors examined
Table 3 Effect of patient pressure on whether doctors investigated
Table 4 Effect of patient pressure on whether doctors referred
We found no evidence that randomisation group, duration of consultation, or potential patient factors significantly confounded the estimates from the study (see bmj.com).
Discussion
Little PS, Williamson I, Warner G, Gould C, Gantley M, Kinmonth AL. An open randomised trial of prescribing strategies for sore throat. BMJ 1997;314: 722-7.
Little PS, Gould C, Williamson I, Warner G, Gantley M, Kinmonth AL. Reattendance and complications in a randomised trial of prescribing strategies for sore throat: the medicalising effect of prescribing antibiotics. BMJ 1997;315: 350-2.
Scott A, Shiell A, King M. Is general practitioner decision making associated with patient socio-economic status. Soc Sci Med 1996;42: 35-46.
Illich I. Medical nemesis. London: Calder and Bryers, 1975.
Illich I. Death undefeated. BMJ 1995;311: 1652-3.
Sharpe V, Faden A. Medical harm. Historical, conceptual, and ethical dimensions of iatrogenic illness. Cambridge: Cambridge University Press, 1998.
Howie J, Heaney D, Maxwell M, Walker J, Freeman G, Rai H. Quality at general practice consultations: cross sectional survey. BMJ 1999;319: 738-43.
Britten N, Ukoumunne O. The influence of patients' hopes of receiving a prescription on doctors' perceptions and the decision to prescribe: a questionnaire survey. BMJ 1997;315: 1506-10.
MacFarlane J, Holmes W, MacFarlane R, Britten N. Influence of patients' expectations on antibiotics management of acute lower respiratory illness in general practice: questionnaire study. BMJ 1997;315: 1211-4.
Cockburn J, Pit S. Prescribing behaviour in clinical practice: patients' expectations and doctors' perceptions of patients' expectations—a questionnaire study. BMJ 1997;315: 520-3.
Barry C, Bradley C, Britten N, Stevenson F, Barber N. Patients' unvoiced agendas in general practice consultations: qualitative study. BMJ 2000;320: 1246-50.
Britten N, Stevenson F, Barry C, Barber N, Bradley C. Misunderstandings in prescribing decisions in general practice: qualitative study. BMJ 2000;320: 484-8.
Little P, Cantrell T, Roberts L, Chapman J, Langridge J, Pickering R. Why do GPs perform investigations?: The medical and social agendas in arranging back X-rays. Fam Pract 1998;15: 264-5.
Wilkin D, Hallam L, Doggett AM. Measures of need and outcome for primary health care. Oxford: Oxford University Press, 1992.
Paterson C. Measuring outcomes in primary care: a patient generated measure, MYMOP, compared with the SF-36 health survey. BMJ 1996;312: 1016-20.
Her Majesty's Stationery Office, Office of Population Censuses and Surveys. Morbidity statistics from general practice: fourth national study 1991. London: HMSO, 1994.
Jewell D, Sanders J, Sharp D. The views and anticipated needs of women in early pregnancy. Br J Obstet Gynaecol 2000;107: 1237-40.
Little P, Dorward M, Warner G, Moore M, Stephens K, Senior J, Kendrick T. Randomised controlled trial of effect of leaflets to empower patients in consultations in primary care BMJ 2004; 441-4.
Thomson O'Brien MA, Oxman AD, Davis DA, Haynes RB, Freemantle N, Harvey EL. Educational outreach visits: effects on professional practice and health care outcomes. Cochrane Database Syst Rev 2000;(2): CD000409 .
Jones M, Greenfield S, Bradley C. Prescribing new drugs: qualitative study of influences on consultants and general practitioners. BMJ 2001;323: 378.
Stevenson F, Greenfield S, Jones M, Nayak A, Bradley C. GPs' perceptions of patient influence on prescribing. Fam Pract 1999;16: 255-61.
Bradley C. Factors which influence the decision whether or not to prescribe: the dilemma facing general practitioners. Brit J Gen Pract 1992;42: 454-8.(Paul Little, professor of)
Correspondence to: P Little psl3@soton.ac.uk
Abstract
General practitioners act as the gateway to most prescribing, investigation, and referral. This has enormous implications for the use of resources in secondary care, "medicalisation," and iatrogenesis, particularly if management is unwittingly inappropriate or ineffective.1-6 Investigating and referring also take time—the main resource in primary care and a major determinant of quality of care.7
Doctors' incorrect perceptions of patients' expectations predict prescribing, and, as doctors tend not to elicit patients' expectations or unvoiced agendas, this results in unnecessary prescriptions and poor compliance.8-12 Most quantitative studies have not, however, controlled for perceived medical need: it may be that when this is controlled for there is little impact on doctors' behaviour from perceived patient pressure. Patients' personal characteristics influence referral and investigation, and a questionnaire survey of doctors showed a variety of non-medical factors that influence decisions to investigate.3 13 Yet little work has been done to quantify doctors' perceptions of pressures from patients in consultations which lead to physical examination, further investigation, and referral. Given the importance of appropriate referrals and investigations it cannot simply be extrapolated that all doctor behaviours are the same. We therefore assessed the relative impact of patient pressure and doctors' perception of that pressure on a range of doctor behaviours in the consultation, while assessing and controlling for perceived medical need.
Methods
We recruited fewer patients from doctors with short (< 9 minutes) consultation times (14 patients 30 patients) because we had less time in which to comply with study protocols before the consultation. We obtained information on 45 consecutive patients booked to see doctors with long consultation times (where nearly all eligible patients could be approached): 14 (31%) were excluded (six were receiving treatment for anxiety or depression, four were out of our age range, two were too ill, and two only collected prescriptions). Of the 31 eligible patients, 17 (55%) agreed to participate. They were similar to those who did not agree for age and chronic medical problems. We received all questionnaires completed before the consultation, 418 (76%) of those completed after the consultation, and 612 (96%) completed by the doctors.
The characteristics of the study group were similar to previous national samples for the population attending general practitioners for age and being male, in paid work, and married.16
Patients who failed to complete the post-consultation questionnaire were similar to those who completed the study for worry about problem, feeling unwell, seeing usual doctor, and whether problem was new or ongoing.
Tables 1, 2, 3, 4 show the impact of different pressures predicting each doctor behaviour. The doctors' perception of medical need was the strongest factor for determining behaviour in the consultation and significantly confounded the predictive value of both patient pressure and perceived patient pressure (change in odds ratios > 50%). The doctors thought, however, there was no or only slight medical need among a significant proportion of those examined (89/580, 15%), given a prescription (74/394, 19%), or referred (27/125, 22%) and among almost half of those investigated (99/216, 46%). After perceived medical need was controlled for, perceived patient pressure was an independent predictor of doctors' behaviour for all behaviours, and a stronger predictor than patients' preferences measured before the consultation.
Table 1 Effect of patient pressure on whether doctors prescribed
Table 2 Effect of patient pressure on whether doctors examined
Table 3 Effect of patient pressure on whether doctors investigated
Table 4 Effect of patient pressure on whether doctors referred
We found no evidence that randomisation group, duration of consultation, or potential patient factors significantly confounded the estimates from the study (see bmj.com).
Discussion
Little PS, Williamson I, Warner G, Gould C, Gantley M, Kinmonth AL. An open randomised trial of prescribing strategies for sore throat. BMJ 1997;314: 722-7.
Little PS, Gould C, Williamson I, Warner G, Gantley M, Kinmonth AL. Reattendance and complications in a randomised trial of prescribing strategies for sore throat: the medicalising effect of prescribing antibiotics. BMJ 1997;315: 350-2.
Scott A, Shiell A, King M. Is general practitioner decision making associated with patient socio-economic status. Soc Sci Med 1996;42: 35-46.
Illich I. Medical nemesis. London: Calder and Bryers, 1975.
Illich I. Death undefeated. BMJ 1995;311: 1652-3.
Sharpe V, Faden A. Medical harm. Historical, conceptual, and ethical dimensions of iatrogenic illness. Cambridge: Cambridge University Press, 1998.
Howie J, Heaney D, Maxwell M, Walker J, Freeman G, Rai H. Quality at general practice consultations: cross sectional survey. BMJ 1999;319: 738-43.
Britten N, Ukoumunne O. The influence of patients' hopes of receiving a prescription on doctors' perceptions and the decision to prescribe: a questionnaire survey. BMJ 1997;315: 1506-10.
MacFarlane J, Holmes W, MacFarlane R, Britten N. Influence of patients' expectations on antibiotics management of acute lower respiratory illness in general practice: questionnaire study. BMJ 1997;315: 1211-4.
Cockburn J, Pit S. Prescribing behaviour in clinical practice: patients' expectations and doctors' perceptions of patients' expectations—a questionnaire study. BMJ 1997;315: 520-3.
Barry C, Bradley C, Britten N, Stevenson F, Barber N. Patients' unvoiced agendas in general practice consultations: qualitative study. BMJ 2000;320: 1246-50.
Britten N, Stevenson F, Barry C, Barber N, Bradley C. Misunderstandings in prescribing decisions in general practice: qualitative study. BMJ 2000;320: 484-8.
Little P, Cantrell T, Roberts L, Chapman J, Langridge J, Pickering R. Why do GPs perform investigations?: The medical and social agendas in arranging back X-rays. Fam Pract 1998;15: 264-5.
Wilkin D, Hallam L, Doggett AM. Measures of need and outcome for primary health care. Oxford: Oxford University Press, 1992.
Paterson C. Measuring outcomes in primary care: a patient generated measure, MYMOP, compared with the SF-36 health survey. BMJ 1996;312: 1016-20.
Her Majesty's Stationery Office, Office of Population Censuses and Surveys. Morbidity statistics from general practice: fourth national study 1991. London: HMSO, 1994.
Jewell D, Sanders J, Sharp D. The views and anticipated needs of women in early pregnancy. Br J Obstet Gynaecol 2000;107: 1237-40.
Little P, Dorward M, Warner G, Moore M, Stephens K, Senior J, Kendrick T. Randomised controlled trial of effect of leaflets to empower patients in consultations in primary care BMJ 2004; 441-4.
Thomson O'Brien MA, Oxman AD, Davis DA, Haynes RB, Freemantle N, Harvey EL. Educational outreach visits: effects on professional practice and health care outcomes. Cochrane Database Syst Rev 2000;(2): CD000409 .
Jones M, Greenfield S, Bradley C. Prescribing new drugs: qualitative study of influences on consultants and general practitioners. BMJ 2001;323: 378.
Stevenson F, Greenfield S, Jones M, Nayak A, Bradley C. GPs' perceptions of patient influence on prescribing. Fam Pract 1999;16: 255-61.
Bradley C. Factors which influence the decision whether or not to prescribe: the dilemma facing general practitioners. Brit J Gen Pract 1992;42: 454-8.(Paul Little, professor of)