Do patients really demand unnecessary imaging studies?

While conventional wisdom suggests that patients are responsible for urging their doctors to perform unnecessary tests and studies that inflate healthcare costs, a new study has found that patients really aren’t to blame.

The study was carried out by a team of researchers from the Abramson Cancer Center and the Perelman School of Medicine at the University of Pennsylvania and was published in the inaugural issue of JAMA Oncology.

For the purposes of the study, 60 clinicians from Philadelphia-area hospitals were surveyed, including 34 oncologists, 11 oncology fellows, and 15 nurse practitioners and physician assistants. They were asked, “During today’s visit, did the patient request or demand a specific test or treatment?” A “yes” response resulted in a series of questions to determine the frequency of these patients’ requests, the appropriateness of those requests, and whether they were granted, and why.

"We decided to look specifically at cancer patients' demands because oncology is a setting where there are life-and-death stakes for patients and the drugs and tests can get very expensive," said senior author Ezekiel Emanuel, MD, PhD, chair of the department of Medical Ethics and Health Policy at Penn, in an announcement. "However, we found, contrary to expectations, that patient demands are low and cannot be a key driver of increasing health care costs."

The researchers looked at 5,050 patient encounters and found that 8.7% (440) included a patient’s request or demand for a medical intervention. Physicians complied with 365 requests they deemed clinically appropriate, but only 50 requests were considered to be inappropriate. Of those 50, physicians complied with only seven requests (0.14% of the 5,050 total patient encounters).

About half of the tests requested (49.1%) were for imaging. Other kinds of requests or demands included palliative care and symptom management (15%), laboratory tests (13.6), genetic tests or chemosensitivity tests (5.2%), chemotherapy (3.6%) and proton beam therapy (0.7%).

As for the 50 clinically inappropriate requests, 18 (36.0%) were for imaging studies, 8 (16.0%) were for laboratory tests such as tumor markers, 9 (18.0%) were for chemosensitivity assays, 2 (4.0%) were for proton beam therapy, 2 (4.0%) were for chemotherapy, 2 (4.0%) were for clinical trials, 1 (2.0%) was for palliative care, and 8 (16.0%) were for other interventions such as intravenous fluids and shingles vaccine.

The seven requests deemed inappropratate that physicians complied with included two blood tests, two imaging tests, two chemosensitivity analyses, and one request for hemodialysis.

“Physicians often identify ‘demanding patients’ as fueling high health care costs,” the authors concluded. Yet, in an outpatient oncology setting “fewer than 9% of encounters do patients demand or request tests or treatments, and most of those are clinically appropriate.”