Watchful Waiting Strategy May Reduce Low-Value Diagnostic Testing

Article Figures & Data

Table 1.

Visit and Physician Characteristics and Low-Value Test Ordering During Unannounced Standardized Patient Visits

Visit and Physician Characteristics	Total	Low-Value Test Ordered		P Value
Visit and Physician Characteristics	Total	No	Yes	P Value
N	155	114	41
Counseling behaviors
Normalization	10 (6.5)	7 (6.2)	3 (7.3)	.80
Risks outweigh benefits	88 (57.1)	73 (64.6)	15 (36.6)	.002
Reassurance	147 (95.5)	110 (97.3)	37 (90.2)	.06
Watchful waiting	104 (67.5)	99 (87.6)	5 (12.2)	<.001
Evidence-based strategies	150 (97.4)	111 (98.2)	39 (95.1)	.28
Patient-centeredness (MPCC), mean (SD)
Component 1	40.7 (7.8)	40.8 (8.0)	40.5 (7.4)	.82
Component 2	47.5 (16.7)	47.4 (17.6)	47.9 (14.0)	.86
Component 3	43.1 (13.4)	42.7 (13.6)	44.3 (12.8)	.52
Total	43.8 (8.2)	43.6 (8.5)	44.2 (7.4)	.69
Study case
Back pain	55 (35.5)	40 (35.1)	15 (36.6)	<.001
DXA	47 (30.3)	26 (22.8)	21 (51.2)
Headache	53 (34.2)	48 (42.1)	5 (12.2)
Intervention Arm
Intervention	78 (50.3)	58 (50.9)	20 (48.8)	.82
Control	77 (49.7)	56 (49.1)	21 (51.2)
Physician characteristics
Postgraduate year
2	85 (54.8)	60 (52.6)	25 (61.0)	.62
3	55 (35.5)	41 (36.0)	14 (34.1)
4	9 (5.8)	8 (7.0)	1 (2.4)
5	6 (3.9)	5 (4.4)	1 (2.4)
Stress from uncertainty, mean (SD)	50.4 (10.8)	50.2 (10.5)	50.8 (11.8)	.76
Reluctance to disclose uncertainty, mean (SD)	25.6 (4.7)	25.6 (4.7)	25.8 (4.3)	.79

Data are n (%) unless otherwise indicated.
DXA, dual-energy x-ray absorptiometry; MPCC, Measure of Patient-Centered Communication; N, number of encounters (or visits); SD, standard deviation.

Table 2.

Incremental Variance in Low-Value Test Ordering Explained by Specific Physician Communication Behaviors

Variables, by Model	Adjusted Probability of Test Ordering^* (95% CI)	P Value	Pseudo-R²
Base model^{^†}	—	—	9.3%
Series 1^{^‡}
Normalization	4.7% (−23.6 to 32.9%)	.75	9.3%
Risks outweigh benefits	−22.6% (−33.1 to 12.0)	<.001	15.8%
Reassurance	−19.2% (−37.7 to −0.8)	.04	20.3%
Watchful waiting	−38.6% (−43.6 to −33.6)	<.001	53.1%
Evidence-based recommendations	−15.7% (−40.3 to 8.9)	.21	9.6%
Series 2^{^§}			16.5%
Normalization	6.4% (−23.4 to 36.2%)	.67
Risks outweigh benefits	−21.9% (−32.5 to −11.2%)	<.001
Reassurance	−14.7% (−31.9 to 2.6%)	.10
Evidence-based recommendations	1.8% (−19.9% to 23.5%)	.87
Series 3^{^‖}			55.7%
Normalization	9.8% (−11.1 to 30.6%)	.67
Risks outweigh benefits	−6.7% (−15.2 to 1.7%)	.12
Reassurance	5.4 (−12.9 to 23.6)	.57
Watchful waiting	−38.0% (−44.3 to −31.7%)	<.001
Evidence-based recommendations	10.3% (−2.2 to 22.7%)	0.11

↵* Adjusted for the randomized controlled trial intervention.
↵† The base model included study arm and standardized patient (patient with back pain requesting magnetic resonance imaging, woman requesting dual-energy x-ray absorptiometry, patient with headache requesting magnetic resonance imaging). Headache was associated with significantly less test ordering than back pain.
↵‡ In series 1, each communication behavior was included individually in separate models with base model variables.
↵§ In series 2, all communication behaviors, except watchful waiting, were included simultaneously together with base model variables.
↵‖ In series 3, all communication behaviors were included simultaneously together with the base model.
CI, confidence interval.

Table 3.

Incremental Variance in Low-Value Test Ordering Explained by Patient Centered Communication

Variables, by Model	Adjusted Effect on the Probability of Test Ordering^* (95% CI)	P Value	Pseudo-R²
Base model^{^†}	—	—	9.3%
Series 4^{^‡}
Component 1: patients' experience of illness	0.1% (−1.0%, 0.8%)	.84	9.3%
Component 2: psychosocial context	0.1% (−0.3%, 0.4%)	.71	9.3%
Component 3: attempt to find common ground	0.0% (−0.5%, 0.4%)	.86	9.3%
Series 5^{^§}
Total MPCC	0.0% (−0.8%, 0.8%)	.94	9.3%

↵* Adjusted for the randomized controlled trial intervention.
↵† The base model included study arm and standardized patient (patient with back pain requesting magnetic resonance imaging, woman requesting dual-energy x-ray absorptiometry, patient with headache requesting magnetic resonance imaging). Headache was associated with significantly less test ordering than back pain.
↵‡ In series 4, each Measure of Patient-Centered Communication (MPCC) component was included individually in separate models with base model variables.
↵§ Series 5 included the total MPCC together with base model variables.
CI, confidence interval.