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Importance of patient pressure and perceived pressure and perceived medical need for investigations, referral, and prescribing in primary care: nested observational study

Authors
  • Paul Little
  • Martina Dorward
  • Greg Warner
  • Katharine Stephens
  • Jane Senior
  • Michael Moore
Publisher
BMJ Publishing Group Ltd.
Publication Date
Feb 21, 2004
Source
PMC
Keywords
Disciplines
  • Logic
  • Medicine
License
Unknown

Abstract

Primary care Importance of patient pressure and perceived pressure and perceived medical need for investigations, referral, and prescribing in primary care: nested observational study Paul Little, Martina Dorward, Greg Warner, Katharine Stephens, Jane Senior, Michael Moore Abstract Objective To assess how pressures from patients on doctors in the consultation contribute to referral and investigation. Design Observational study nested within a randomised controlled trial. Setting Five general practices in three settings in the United Kingdom. Participants 847 consecutive patients, aged 16-80 years. Main outcomes measures Patient preferences and doctors’ perception of patient pressure and medical need. Results Perceived medical need was the strongest independent predictor of all behaviours and confounded all other predictors. The doctors thought, however, there was no or only a slight indication for medical need among a significant minority of those who were examined (89/580, 15%), received a prescription (74/394, 19%), or were referred (27/125, 22%) and almost half of those investigated (99/216, 46%). After controlling for patient preference, medical need, and clustering by doctor, doctors’ perceptions of patient pressure were strongly associated with prescribing (adjusted odds ratio 2.87, 95% confidence interval 1.16 to 7.08) and even more strongly associated with examination (4.38, 1.24 to 15.5), referral (10.72, 2.08 to 55.3), and investigation (3.18, 1.31 to 7.70). In all cases, doctors’ perception of patient pressure was a stronger predictor than patients’ preferences. Controlling for randomisation group, mean consultation time, or patient variables did not alter estimates or inferences. Conclusions Doctors’ behaviour in the consultation is most strongly associated with perceived medical need of the patient, which strongly confounds other predictors. However, a significant minority of examining, prescribing, and referral, and almost half of investigations, are still thought by the doctor

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