Cancer patient demands rarely lead to unnecessary tests, treatments

The Penn Medicine team, including lead author Keerthi Gogineni, MD, MSHP, an instructor in the division of Hematology-Oncology in the ACC, surveyed 26 oncologists and nurse practitioners immediately after patient encounters at the ACC -- 2,050 in total -- to determine frequency of patient requests or demands for tests and treatment, whether those requests were appropriate, whether they were granted and why.

"The results from this new study help debunk many of the misconceptions people have about patient demands leading to unnecessary tests and treatments as a major source of higher health care costs in the US," said Gogineni. "In this study, inappropriate cancer patient demands were uncommon, and in less than 1 percent of the cases did providers order an inappropriate treatment or test when requested by patients.

"Clinicians felt that the majority of patient directed requests were appropriate. The data suggests that rather than being driven by patients to employ low-value, high cost care, most of the time oncologists and nurse practitioners incorporated patients' requests into a suitable plan of action."

Questions about patient demands were raised last year after results from a study presented at ASCO by Penn Medicine researchers revealed that over 80 percent of the general public, 69 percent of patients, and 70 percent of doctors surveyed believed hospitals and doctors conducted unnecessary tests and provided unnecessary treatments, and over 50 percent believed patients requested unnecessary tests or treatments.

Was this happening and could cancer patient demands be part of the problem? The questions are important ones to explore, particularly in the oncology setting, where drugs and tests can get expensive.

To find out, the team, including Ezekiel J. Emanuel, MD, PhD, chairman of the department of Medical Ethics and Health Policy, broke down the 177 encounters where patients had requests or demands regarding treatment or tests.

The survey revealed that nearly 80 percent of the time the requests or demands from patients were deemed appropriate by the clinician and followed through. The rest were considered inappropriate based on the clinician's judgment and were not ordered. Of the total number of encounters, there were only four instances (0.2 percent) where a clinician ordered an inappropriate test or treatment because of a patient's demand.

The patient base was mostly non-Hispanic white (73 percent) with a mean age of 60. Overall, 42 percent had advanced stage or refractory disease, and 66 percent were undergoing active treatment -- 49.5 percent had palliative intent. Among the 26 clinicians surveyed, 97 percent were white, 54 percent were female and had a median of 14 years of post-training experience. Too few cases of inappropriate test ordering and treatments precluded the team from making any associations with demographics or disease state to the patient or provider base.

"Rightfully, there is a big push towards more cost-effective care," said Gogineni. "Oncology in particular has been under the lens because of expensive tests and treatments that sometimes have marginal positive effects. So it's important to show the influence of demands and requests, which appear to be very uncommon among cancer patients -- and most likely do not drive overutilization of high cost or low-value medical services."