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: 7630977
• 负责人: John B McKinlay
• 金额: $ 53.79万
• 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 2013-03-31
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/7630977
• 关键词: Acetaminophen; Acute; Address; Adherence; Advertising; Affect; Age; Analgesics; Area; Assertiveness; Attitude; Awareness; Behavior; Belief; Caring; Cessation of life; Characteristics; Chronic; Client; Climate; Clinical; Cognitive; Communication; 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; Life Style; Link; Litigation; Measurement; Measures; Medical; Medical Errors; Medical center; Minority; Modeling; Modification; Morbidity - disease rate; 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 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）：在过去的几十年中，美国医疗保健环境发生了巨大变化。患者越来越有能力（通过互联网访问）和“通过直接广告激活”（通过直接广告）寻求在大型医疗环境中越来越受薪员工（遵守组织优先事项）的医生的护理。 “激活的患者”经常建议对其初级保健医生进行特定的诊断。现在，大约30％的人要求特定的药物（在电视或互联网搜索中发现），其中40％的药物收到了要求的处方。使用互补的研究方法（阶乘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应对不同患者的特定处方请求（阶乘实验）； 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一项研究中，我们提出了两个针对常见医疗状况（膝盖的坐骨神经和骨关节炎）的实验，这些实验会产生高水平的医疗保健利用，处方和成本，以解决以下具体目的：1。估计患者归因对物理学对疼痛症状的要求的独立影响。某些患者的要求更可能成功吗？ 2。估计提供商特征对介绍和管理的独立影响。某些医生是否更有可能接受患者的要求？ 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，实践设置或实践文化会影响决策吗？ 4。互补的定性成分将确定基本的认知推理过程，这些过程解释了研究的实验成分发现的决策中观察到的可变性。我们的发现将对旨在提高决策质量的日常临床实践，医疗保健政策和教育干预措施有影响。首先，初级保健医生为普遍表现的疼痛提供的护理质量变异性是全国性的。其次，患者要求对提供者行为的影响仍然很少了解，但在美国和其他地方可能会增加（制药的DTCA将在欧盟的整个国家中引入）。第三，多药（尤其是止痛药）在美国越来越关注，尤其是在具有多种合并症的老年患者中，除初级保健提供者外，还经常咨询一系列专家。第四，从对医疗保健变异的描述（如何？）到解释其认知起源（为什么？）标志着临床决策研究的新方向，并且是教育干预措施的必要前提条件。公共卫生相关性：我们建议使用阶乘实验来了解临床决策（CDM）当激活的患者要求使用特定的止痛药时。对消费者广告（通过互联网，电视和印刷品）的不断直接增加，延长慢性疼痛管理中的健康差异以及慢性疼痛的越来越多的影响具有重大的健康政策影响。这项研究旨在消除患者（性别，种族，SES）和医师因素（经验和性别）与慢性疼痛管理和阿片类药物使用有关的因素（经验和性别），并基本的认知推理产生了我们观察到的决定。