Taking societal cost into clinical consideration: U.S. physicians' views.

BACKGROUND: Recent campaigns (e.g., the American Board of Internal Medicine Foundation's Choosing Wisely) reflect the increasing role that physicians are expected to have in stewarding health care resources. We examine whether physicians believe they should pay attention to societal costs or refuse requests for costly interventions with little chance of patient benefit. METHODS: We conducted a secondary analysis of data from a 2010 national survey of 2016 U.S. physicians sampled from the AMA Physician Masterfile. Criterion measures were agreement or disagreement with two survey items related to costs of care. We also examined whether physicians' practice and religious characteristics were associated with their responses. RESULTS: The adjusted response rate was 62% (1156/1878). Forty-seven percent of physicians agreed that physicians "should not consider the societal cost of medical care when caring for individual patients," whereas 69% agreed that physicians "should refuse requests from patients or their families for costly interventions that have little chance of benefitting the patient." Physicians in specialties that care for patients at the end of life were more supportive of refusing such costly interventions. We did not find consistent associations between physicians' religiosity and their responses to these items, though those least supportive of taking into account societal cost were disproportionately from Christian affiliations. CONCLUSION: Physicians were nearly evenly divided regarding whether they should help control societal costs when caring for individual patients, but a strong majority agreed that physicians should refuse costly interventions that have little chance of benefit.

Understanding Frequent Emergency Department Use Among Primary Care Patients.

Patients with high emergency department (ED) utilization are an important focus in population health management. This retrospective cohort study analyzed patterns of frequent ED use for 4087 patients enrolled at an academically-affiliated primary care clinic. For all ED visits (n = 4776), the chief complaints, admission rates, number of complaints per patient, and median time between return visits were assessed. Chart reviews were conducted for the 10 highest utilizers from each of the 3 leading complaints to help explain repeated ED use for the same complaints. Results showed that chief complaints for high utilizers were statistically similar to other patients. Nearly half (49.8%) of all ED visits among high utilizers were repeat visits for the same complaint. However, most high utilizers (85%) had 4 or more separate complaints. Their visits clustered temporally, with 55% occurring less than 30 days apart. Visits for psychiatric symptoms demonstrated the shortest time to repeat visit (median 17.5 days, interquartile range: 39.5). Abdominal pain, chest pain, and shortness of breath were the leading complaints and the leading sources of hospital admissions and repeat visits. Chart review revealed that these 3 chief complaints often were associated with a wide range of ongoing chronic conditions, confounded by substance abuse, anxiety, and treatment nonadherence. This study demonstrates an integrative method for examining patterns of ED use among high utilizers. It also highlights the complex nature of high utilization and the inherent difficulty in predicting and addressing the needs of high-utilizer patients.