May Larissa, Franks Peter, Jerant Anthony, Fenton Joshua
From the Departments of Emergency Medicine (LM) and Family and Community Medicine (PF, AJ, JF), University of California-Davis, Sacramento, CA.
J Am Board Fam Med. 2016 Nov 12;29(6):710-717. doi: 10.3122/jabfm.2016.06.160056.
PCPs need effective communication strategies to address patient requests for low-value testing while sustaining patient-provider partnerships. Watchful waiting - allowing a negotiated period of time to pass before making a firm testing decision - shows promise as a tool for addressing patient requests for low-value testing.
Observational analysis of data from a randomized controlled trial of a communication intervention designed to boost patient-centeredness and reduce low-value test ordering among 61 resident primary care physicians. Intervention effectiveness was assessed during follow-up encounters of unannounced standardized patients (SPs) who requested low-value tests. We examined associations between five physician counseling behaviors and overall patient-centeredness (Measure of Patient-Centered Communication) and requested test ordering.
During 155 SP encounters, residents most commonly used reassurance (96% of encounters), evidence-based recommendations (97%), and watchful waiting (68 %). Resident advice to pursue watchful waiting was associated with 39% lower likelihood of test ordering (adjusted marginal effect of -38.6% [95% CI -43.6 to -33.6]). When all communication behaviors were examined together, only watchful waiting was significantly associated with test ordering (marginal effect of -38% [95% CI -44.3% to -31.7%]). Overall patient-centeredness was not associated with low-value testing.
Resident physician counseling to pursue watchful waiting was associated with less ordering of requested low-value diagnostic tests, while overall patient-centeredness was not.
初级保健医生（PCP）需要有效的沟通策略，以应对患者对低价值检测的要求，同时维持患者与医生的合作关系。观察等待——在做出明确的检测决定之前，允许经过一段协商好的时间——作为一种应对患者对低价值检测要求的工具，显示出了前景。
对一项旨在提高以患者为中心程度并减少61名住院初级保健医生开出低价值检测医嘱的沟通干预随机对照试验的数据进行观察性分析。在未事先通知的标准化患者（SP）要求进行低价值检测的随访就诊期间，评估干预效果。我们研究了五种医生咨询行为与整体以患者为中心程度（以患者为中心的沟通衡量指标）以及所要求的检测医嘱之间的关联。
在155次SP就诊中，住院医生最常使用的是安慰（96%的就诊）、基于证据的建议（97%）和观察等待（68%）。住院医生建议进行观察等待与检测医嘱开出可能性降低39%相关（调整后的边际效应为-38.6%[95%置信区间-43.6至-33.6]）。当综合考察所有沟通行为时，只有观察等待与检测医嘱开出显著相关（边际效应为-38%[95%置信区间-44.3%至-31.7%]）。整体以患者为中心程度与低价值检测无关。
住院医生建议进行观察等待与所要求的低价值诊断检测医嘱开出减少相关，而整体以患者为中心程度则不然。
