Cancer Patients’ Demands for Medical Interventions Infrequent, Rarely Inappropriate

An empirical assessment of outpatient oncology encounters shows that patients rarely demand or request unnecessary tests or treatments

medwireNews: Patient demands or requests for medical interventions are infrequent in the oncology setting, suggests research published in JAMA Oncology, and when made, are only rarely deemed clinically inappropriate.

In an accompanying editorial, Anthony Back, from the University of Washington in Seattle, USA, says that the study premise that patient demands drive up unnecessary costs was “spectacularly unconfirmed” when investigated empirically.

“Suddenly, the demanding cancer patient looks less like a budget buster and more like an urban myth”, he writes.

Of 5050 encounters involving 3624 patients and 60 clinicians, including oncologists, oncology fellows, nurse practitioners and physician assistants, in outpatient facilities at three hospitals in Philadelphia, USA, patient demands or requests for a medical intervention were made in 440 (8.7%) cases.

Nearly half (49.1%) of the demands or requests were for imaging tests, followed by appeals for palliative care and symptom management (15.5%), laboratory tests (13.6%), clinical trials (6.8%), genetic or chemosensitivity analyses (5.2%), chemotherapeutic interventions (3.6%) and proton beam therapy (0.7%).

Overall, 316 (71.8%) of the demands or requests were judged by the clinicians to be clinically appropriate, with 50 (11.4%) rated as medically inappropriate and 74 (16.8%) as equivocal.

Clinicians complied with 310 (98.1%) of the clinically appropriate demands or requests and with seven (14.0%) of the inappropriate ones, including one haemodialysis request and two each of blood tests, imaging studies and chemosensitivity assays. Clinicians did not agree to provide proton beam therapy, chemotherapy drugs or surgical procedures when requested inappropriately.

Ezekiel Emanuel, from the University of Pennsylvania in Philadelphia, USA, and co-authors write: “[G]iven the rarity of clinically inappropriate demands or requests, that few were high cost, and that few were complied with, they are unlikely to add significantly to health care costs.”

Multivariate analysis showed that patients with lung or head and neck cancer were significantly more likely to make demands or requests than those with other tumour types, as were those receiving active treatment. This was also true for patients with whom the clinicians rated their relationship as poor or fair, but here the study authors note that the causality is not clear.

“Patient demands may make the clinician evaluate the relationship as poorer”, they write. “Conversely, worse patient-clinician relationships with less trust may lead to more demands and requests for treatments; without confidence in the clinician, patients may feel as if they have to be their own agents.”

Editorialist Anthony Back says that in the “age of Wikipedia” patients no longer rely on just their clinicians for information about their condition, signifying a “tectonic shift” in patient–physician dynamics.

He concludes: “This dynamic builds trust between patient and physician so that when they need to face the tough decisions, the medical decision making reflects the patient’s real values and not just their fear.”

References

Gogineni K, Shuman KL, Chinn D, et al. Patient Demands and Requests for Cancer Tests and Treatments. JAMA Oncol 2015; Published online 12 February. doi:10.1001/jamaoncol.2014.197

Back AL. The Myth of the Demanding Patient. JAMA Oncol 2015; Published online 12 February. doi:10.1001/jamaoncol.2014.185

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