Denying Patient Requests May Lower Satisfaction, but Not Always

Marcia Frellick

November 28, 2017

Denying patients' requests for some services results in lower patient satisfaction ratings, but not so for other requests, an observational study finds.

The findings may signal that the way information is communicated affects patient buy-in, and that clinicians need training in how to deal effectively with requests, the authors say. The findings, published online November 27 in JAMA Internal Medicine, also have implications for compensation, as physicians' pay increasingly is dependent on patient satisfaction and experience scores.

Anthony Jerant, MD, from the Department of Family and Community Medicine at the University of California, Davis, School of Medicine in Sacramento, led the cross-sectional study of 1141 adults who made 1319 office visits to 56 family physicians at a single northern California academic health center.

The average age of patients was 45.6 (standard deviation, 16.1) years, and most (902 or 68.4%) of the visits were made by women. Overall, physicians granted 85.2% of the 1441 requests made by patients.

Dr Jerant and colleagues found that patients gave lower satisfaction scores for physicians who denied requests for referrals, laboratory tests, pain medication, and other new medications (nonpain, nonantibiotic) compared with those who granted the requests. In those cases, the satisfaction ratings were approximately 10 to 20 percentiles lower.

Table. Lower Satisfaction Scores Compared With Requests Granted

Denied Request Adjusted Mean Percentile Differences 95% Confidence Interval
Referral −19.75 −30.75 to −8.74
Pain medication −10.72 −19.66 to −1.78
Other medication (nonpain/non antibiotic) −20.36 −29.54 to −11.18
Laboratory tests −9.19 −17.50 to −0.87

However, they did not see any significant reduction in satisfaction scores associated with denials of requests for antibiotics and imaging.

That pattern is not a coincidence, Joseph S. Ross, MD, MHS, from the Yale University School of Medicine, New Haven, Connecticut, and an associate editor of JAMA Internal Medicine, says in an accompanying editor's note.

"Through Choosing Wisely and other campaigns to reduce low-value care, substantial attention has been devoted to preparing physicians to avoid frequently requested, low-value care such as these," he writes. "We can train physicians to say no to other types of clinically inappropriate requests, while still reassuring patients and paying attention to their needs."

The authors have demonstrated that there are ways to engage, inform, and satisfy patients whether requests are granted or denied, he concludes.

The authors say more studies are needed, as their study was not designed to determine the mechanism of the link between satisfaction and fulfillment or denial of requests for services. Moreover, they note, the small sample size in the antibiotics category, for instance, may have affected those results.

"It may also be that clinicians have more experience at denying antibiotic requests than other types of requests, given sustained and publicized efforts to improve antibiotic stewardship," they write.

The study authors adjusted for a variety of factors including patient sociodemographics, personality factors (including extraversion, neuroticism, and openness), body mass index, health status, worry over health, and prior visit with the clinician.

Clinicians have long suspected that denial of patient requests for services was linked to lower patient satisfaction scores, but the subject has been understudied. The authors say prior studies have not adjusted extensively for patient characteristics or type of service requested; for instance, diagnostic test vs treatment.

"This is an important gap," they write, "since research suggests that the strength of patient expectations varies across different aspects of care, and that clinicians perceive some types of requests as more difficult to address than others."

Given these findings, it is important to find ways to help clinicians communicate evidence-based recommendations to patients to reduce overprescribing, while also maintaining patient satisfaction and not adding substantially to the already packed primary care appointment.

One potential approach is for clinicians to take the wait-and-see approach when patients make requests for services that are not clearly indicated. That has advantages in being quick and offering patients a middle ground.

The authors write, "In an observational analysis, we found that a clinician offer of a watchful waiting option was associated with less low-value test ordering, with no decrement in patient satisfaction."

However, they acknowledge that few randomized clinical trials have been conducted on this method, and none has examined its effectiveness in primary care patients' requests.

This work was supported by the University of California, Davis, Department of Family and Community Medicine. A coauthor was supported by the National Center for Advancing Translational Sciences at the National Institutes of Health. The authors of the study and Dr Ross have disclosed no relevant financial relationships.

JAMA Intern Med. Published online November 27, 2017. Article abstract, Editor's note extract

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