Older patients perceptions of "unnecessary" tests and referrals: a national survey of Medicare beneficiaries

Abstract

Context: Unnecessary exposure to medical interventions can harm patients. Many hope that generalist physicians can limit such unnecessary exposure.

Objective: To assess older Americans' perceptions of the need for tests and referrals that their personal physician deemed unnecessary.

Design: Telephone survey with mail follow-up in English and Spanish, conducted from May to September 2005 (overall response rate 62%).

Study participants: Nationally representative sample of 2,847 community-dwelling Medicare beneficiaries. Main analyses focus on the 2,319 who had a personal doctor ("one you would see for a check-up or advice if you were sick") whom they described as a generalist ("doctor who treats many different kinds of problems").

Main outcome measure: Proportion of respondents wanting a test or referral that their generalist suggested was not necessary using 2 clinical vignettes (cough persisting 1 week after other flu symptoms; mild but definite chest pain lasting 1 week).

Results: Eighty-two percent of Medicare beneficiaries had a generalist physician; almost all (97%) saw their generalist at least once in the past year. Among those with a generalist, 79% believed that it is "better for a patient to have one general doctor who manages most of their medical problems" than to have each problem cared for by a specialist. Nevertheless, when faced with new symptoms, many would want tests and referrals that their doctor did not think necessary. For a cough persisting 1 week after flu symptoms, 34% would want to see a lung specialist even if their generalist told them they "probably did not need to see a specialist but could if they wanted to." For 1 week of mild but definite chest pain when walking up stairs, 55% would want to see a heart specialist even if their generalist did not think it necessary. In these same scenarios, even higher proportions would want diagnostic testing; 57% would want a chest x-ray for the cough, and 74% would want "special tests" for the chest pain.

Conclusions: When faced with new symptoms, many older patients report that they would want a diagnostic test or specialty referral that their generalist thought was unnecessary. Generalists striving to provide patient-centered care while at the same time limiting exposure to unnecessary medical interventions will need to address their patients' perceptions regarding the need for these services.

Figure 1

Selection of survey sample.

Figure 2

Elderly Americans with a generalist personal physician who would want a test or specialty referral that their doctor did not think was necessary (N = 2,319)*.

Figure 3

Desire for tests and referrals by patient characteristics (adjusted for all characteristics in Table 2), the mean number of the 4 possible tests or referrals desired by patient characteristics (after adjusting for all characteristics in Table 2). The absolute differences within each patient characteristic are presented graphically—this represents how many tests or referrals patients desired compared to the referent category (difference = 0).