Hèlen Koch

Influence of Watchful Waiting on Satisfaction and Anxiety Among Patients Seeking Care for Unexplained Complaints

PURPOSE We undertook a study to determine whether test-ordering strategy and other consultation-related factors influence satisfaction with and anxiety after a consultation among patients seeking care for unexplained complaints. METHODS A cluster-randomized clinical trial was conducted in family medicine practices in the Netherlands. Participants were 498 patients with unexplained complaints seen by 63 primary care physicians. Physicians either immediately ordered a blood test for patients or followed a 4-week watchful waiting approach. Physicians and patients completed questionnaires asking about their characteristics, satisfaction with care, and anxiety, and aspects of the consultation. The main outcomes were patient satisfaction and anxiety. Data were analyzed by multilevel logistic regression analysis. RESULTS Patients were generally satisfied with their consultation and had moderately low anxiety afterward (mean scores on 11-point scales, 7.3 and 3.1, respectively), with no difference between the immediate testing and watchful waiting groups (χ2 = 2.4 and 0.3, respectively). The factors associated with higher odds of satisfaction were mainly related to physician-patient communication: patients’ satisfaction with their physician generally, feeling taken seriously, and knowing the seriousness of complaints afterward; physicians’ discussing testing and not considering complaints bearable; and older physician age. The same was true for factors associated with higher odds of anxiety: patients expecting testing or referral, patients not knowing the seriousness of their complaints afterward, and physicians not seeing a cause for alarm. CONCLUSIONS Test-ordering strategy does not influence patients’ satisfaction with and anxiety after a consultation. Instead, specific aspects of physician-patient communication are important. Apparently, primary care physicians underestimate how much they can contribute to the well-being of their patients by discussing their worries.

Ordering blood tests for patients with unexplained fatigue in general practice: what does it yield? Results of the VAMPIRE trial

BACKGROUND Unexplained fatigue is frequently encountered in general practice. Because of the low prior probability of underlying somatic pathology, the positive predictive value of abnormal (blood) test results is limited in such patients. AIM The study objectives were to investigate the relationship between established diagnoses and the occurrence of abnormal blood test results among patients with unexplained fatigue; to survey the effects of the postponement of test ordering on this relationship; and to explore consultation-related determinants of abnormal test results. DESIGN OF STUDY Cluster randomised trial. SETTING General practices of 91 GPs in the Netherlands. METHOD GPs were randomised to immediate or postponed blood-test ordering. Patients with new unexplained fatigue were included. Limited and expanded sets of blood tests were ordered either immediately or after 4 weeks. Diagnoses during the 1-year follow-up period were extracted from medical records. Two-by-two tables were generated. To establish independent determinants of abnormal test results, a multivariate logistic regression model was used. RESULTS Data of 325 patients were analysed (71% women; mean age 41 years). Eight per cent of patients had a somatic illness that was detectable by blood-test ordering. The number of false-positive test results increased in particular in the expanded test set. Patients rarely re-consulted after 4 weeks. Test postponement did not affect the distribution of patients over the two-by-two tables. No independent consultation-related determinants of abnormal test results were found. CONCLUSION Results support restricting the number of tests ordered because of the increased risk of false-positive test results from expanded test sets. Although the number of re-consulting patients was small, the data do not refute the advice to postpone blood-test ordering for medical reasons in patients with unexplained fatigue in general practice.

What makes general practitioners order blood tests for patients with unexplained complaints? A cross-sectional study.

Background: Approximately 13% of consultations in general practice involve patients with unexplained complaints (UCs). These consultations often end with general practitioners (GPs) ordering blood tests of questionable diagnostic informativeness. Objective: We studied factors potentially associated with GPs’ decisions to order blood tests. Methods: Cross-sectional study. Twenty-seven GPs completed registration forms after each consultation concerning newly presented UCs. Results: Of the 100 analysable patients, 59 had at least one blood test ordered. The median number of ordered tests was 10 (interpercentile range [IPR-90] 2–15). Compared to abdominal complaints, the blood test ordering (BTO) probability for fatigue was five times higher (relative risk [RR] 5.2). Duration of complaints for over 4 weeks also increased this probability (RR 1.6). Factors associated with a lower BTO probability were: likelihood of background psychosocial factors (RR 0.4) and GPs having a syndrome rather than symptom type of working hypothesis (RR 0.5). Conclusion: We found a high rate of BTO among GPs confronted with patients with UCs. Furthermore, a considerable number of tests were ordered. The selectivity in BTO behaviour of GPs can be improved upon.

Special methodological challenges when studying the diagnosis of unexplained complaints in primary care

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The effect of watchful waiting compared to immediate test ordering instructions on general practitioners' blood test ordering behaviour for patients with unexplained complaints; a randomized clinical trial (ISRCTN55755886)

BackgroundImmediate blood testing for patients presenting with unexplained complaints in family practice is superfluous from a diagnostic point of view. However, many general pracitioners (GPs) order tests immediately. Watchful waiting reduces the number of patients to be tested and the number of false-positive results. The objectives of this study are: to determine the feasibility of watchful waiting compared to immediate test ordering; to determine if a special quality improvement strategy can improve this feasibility; and to determine if watchful waiting leads to testing at a later time.MethodsThe study is a cluster-randomized clinical trial with three groups, on blood test ordering strategies in patients with unexplained complaints. GPs in group one were instructed to order tests immediately and GPs in group two to apply a watchful waiting approach. GPs in group three received the same instruction as group two, but they were supported by a systematically designed quality improvement strategy. A total of 498 patients with unexplained complaints from 63 practices of Dutch GPs participated. We measured: the percentage of patients for whom tests were ordered and number of tests ordered at the first consultation; performance on the strategys performance objectives (i.e., ordering fewer tests and specific communication skills); the number of tests ordered after four weeks; and GP and patient characteristics.ResultsImmediate test ordering proved feasible in 92% of the patients; watchful waiting in 86% and 84%, respectively, for groups two and three. The two watchful waiting groups did not differ significantly in the achievement of any of the performance objectives. Of the patients who returned after four weeks, none from group one and six from the two watchful waiting groups had tests ordered for them.ConclusionsWatchful waiting is a feasible approach. It does not lead to testing immediately afterwards. Furthermore, watchful waiting was not improved by the quality improvement strategy.Trial registrationClinical trial registration: ISRCTN55755886