Abstract
Background: Imaging tests are a widely used tool in primary care with many known benefits. Without an understanding of which outcomes matter the most to patients, clinicians are challenged to balance the benefits and harms of imaging tests. This study aimed to explore the perceived impacts imaging tests have on patients from the perspective of the primary care providers (PCPs) and determine PCPs' understanding of patient-centered outcomes (PCOs) from imaging tests.
Methods: Recruitment of PCPs occurred at 4 family medicine clinics in Washington and Idaho. Primary care physicians, nurse practitioners, or physician assistants who order imaging tests were eligible to participate. Semistructured interviews explored providers' perceptions of patient experiences during the process of ordering, performing and following up on imaging tests. Classic content analysis generated themes and subthemes.
Results: Sixteen PCPs, including 11 physicians, 3 physician assistants, and 2 nurse practitioners, completed interviews. Two themes were identified: 1) perceived PCOs, and 2) factors influencing the incorporation of PCOs into clinical management. Perceived outcomes included emotions related to the answer a test provides and costs to the patient such as monetary, physical, and added risk. Patient expectations, provider-patient communication, and inadequate knowledge all contributed as barriers to incorporating PCOs into clinical management.
Discussion: PCPs recognize different outcomes of imaging tests that they consider important for patients. While providers are perceptive to patient outcomes there remains a challenge to how patient outcomes are used to improve care. Communication with patients and improving provider knowledge are needed to incorporate identified PCOs.
- Family Physicians
- Nurse Practitioners
- Physician Assistants
- Primary Health Care
- Qualitative Research
- Shared Decision Making
One in 6 US ambulatory care office visits results in imaging tests,1 frequently ordered inappropriately. Unnecessary testing was identified by 73% of physicians as a serious problem,2 exposing patients to avoidable harms.3 Drivers of overuse include overestimation of test benefits, diagnostic uncertainty, medico-legal concerns, and patient requests.4
Physicians report that having evidence-based recommendations to share with patients about care options would help encourage appropriate testing.2 In addition to diagnostic accuracy, recommendations should be based on outcomes of importance to patients—known as patient-centered outcomes (PCOs). Understanding which PCOs are most important could help align imaging decisions in primary care with patient values and preferences.
This qualitative study aims to explore primary care providers' (PCPs') perspectives on the impact of imaging tests on patients, to inform understanding of how PCPs and patients could better navigate the benefit and risk tradeoffs of imaging decisions together. This is the second of 3 qualitative studies from the Patient-Centered Research for Standards of Outcomes in Diagnostic Tests (PROD) Study, a multi-year project to identify PCOs of imaging tests through the experiences of patients, PCPs, and radiologists.
Methods
A convenience sample of PCPs from 4 primary care clinics across Washington and Idaho were recruited from a 5-state practice and research network. At each site, recruitment flyers were circulated at provider meetings and through staff email. Eligible PCPs were family physicians, internists, family medicine nurse practitioners, or family medicine physician assistants. The University of Washington Human Subjects Division approved the study. All participants provided informed consent.
Interview guides were informed by existing PCO literature related to diagnostic testing, PCOs identified from patient interviews and the PROD study stakeholder advisory board (consisting of patient advocates, caregivers, clinicians, methodologists, and nonprofit and industry representatives).5,6 Site champions reviewed the guides to confirm clinical and cultural relevancy of the questions.
Interview guides were organized into 4 sections: 1) PCP reasons for ordering imaging tests, 2) PCP observations of the impact of imaging tests on patients, 3) PCP experiences communicating imaging test information, and 4) provider demographics. Participants completed a single audio-recorded interview, conducted in-person or by phone by trained interviewers (MZS or MJT). Recordings were professionally transcribed and identifiers removed. Two researchers crosschecked transcripts against the audio-recordings for accuracy. Interviews ranged from 40 to 60 minutes and were conducted from January to March 2017. Study data were maintained in a Research Electronic Data Capture (REDCap) database.7
Data interpretation was based on classic content analysis methods.8,9 PCOs from patient interviews guided development of criteria for defining data. Through immersion, 3 transcripts were open coded by 2 coders (MZS, VH) to identify initial codes.6 These were discussed and differences reconciled by a third researcher (MJT). Remaining transcripts were double-coded with revised codes (MZS, VH) and reconciled in the same manner. Researchers (MJT, MZS, VH) interpreted the results of coding by grouping text excerpts into categories and subcategories to create final patient experience themes as perceived by the PCPs.10 Data collection continued to the point of theoretical saturation.
Results
Sixteen PCPs (11 physicians, 3 physician assistants, and 2 nurse practitioners) participated (Table 1). Years since completing medical training ranged from 3 to 43. Ultrasound and/or radiograph imaging were available onsite at 3 of the 4 clinics; all other imaging was conducted offsite. PCPs were perceptive to patients' experiences through general observations, anecdotes, and interactions. Analysis revealed 2 main thematic outcomes: imaging tests' ability to provide answers influences emotional outcomes, and the burden of the test to the patient. We also identified a third theme around the factors that influenced these outcomes.
Characteristic of Primary Care Providers (PCPs) Interviewed
Thematic Perceived Patient Outcomes
Outcome 1: Imaging Tests' Ability to Provide Answers Influences Emotional Outcomes
PCPs recognized positive and negative impacts of imaging tests on emotions through tests' capacity to yield a diagnosis or clinically helpful information. PCPs perceived that the test often had significant emotional impact on patients, depending on results (Table 2). PCPs reported that patients displayed feelings of worry, anxiety, disappointment, discomfort, and frustration after inconclusive results. Benign incidental findings created additional patient concerns. PCPs felt that patients experienced stress while waiting for testing results, which often influenced when and how PCPs communicated to patients. Finally, when a conclusive test contributed to a management plan or definitive diagnosis, PCPs felt imaging led to patient feelings of hope, relief, and reassurance.
Perceived Patient Outcomes Identified by PCPs and Exemplary Excerpts
Outcome 2: Burden (Monetary, Added Risk, Physical Effects) to the Patient
PCPs believed financial costs of tests negatively impacted some patients (Table 2), but acknowledged that the financial burden of imaging testing might not be evident to all patients. Although PCPs attempted to be cognizant of cost, they noted that they were often unaware of the cost, preventing cost from factoring into imaging decisions. PCPs understood downstream effects of tests on patients, such as the need for additional testing. However, they acknowledged that these were not obvious to their patients, representing a potential unappreciated added risk. Patients who were initially receptive to testing subsequently experienced regret from costs and effort associated with additional interventions. PCPs also noted the burden associated with negative physical effects of tests, including pain or discomfort (eg, from holding a certain body position), contrast material reactions, or claustrophobia.
Mediators that Influence Outcomes in Imaging Testing
PCPs noted several factors impeding their ability to discuss and improve PCOs in patient care of imaging tests (Table 3).
Influencers of Patient Outcomes in Imaging Testing Settings and Exemplary Excerpts
Patient-Provider Communication
PCPs noted that communicating the steps of the decision making process and what to expect from tests were difficult. PCPs reported potential pitfalls of providing too much information that could cause undue stress. Insufficient consultation time was noted as a major impediment to discussing testing options. The strength of the patient-provider relationship influenced test-ordering and communication. PCPs with a long-standing patient relationship could determine patient needs more easily and the relationship allowed greater diagnostic uncertainty. PCPs described a more cautious approach with new patients because of unfamiliarity with their medical history.
Inadequate Knowledge
PCPs had limited knowledge about certain risks and benefits of imaging tests, including inadequate knowledge of physical risks and costs. PCPs noted this significantly impaired their ability to compare the pros and cons of alternative tests, negatively impacting shared decision making. Furthermore, PCPs perceived limitations to patients' abilities to understand complex terminology as another potential barrier to discussing imaging tests.
Patient Expectations
PCPs received requests from patient for imaging tests, and these were often based on fears of diagnoses, information learned from the internet, or anecdotes. Patient expectations for imaging often directed what was communicated. PCPs struggled to reconcile patient demand with test performance and consequences, including false reassurance, failure to provide definitive diagnoses, and further testing.
Discussion
Our study provides new information on outcomes that PCPs perceive are important to patients undergoing imaging tests and identifies factors influencing how PCOs are integrated in clinical management. We identified 2 main patient outcomes of imaging testing: emotional outcomes from imaging test results and patient burden (monetary, added risk, physical effects). PCPs' ability to incorporate PCOs in their discussions and shared decision making with patients was enhanced by familiarity with patients through existing relationships. PCPs found it difficult to quantify and discuss risks and benefits with patients. In some cases patient requests drove test ordering, which were perceived by PCPs to be based on incomplete patient understanding of risks and benefits.
Previous research on the impacts of imaging testing on patients, from PCPs' perspectives, is limited to communication, clinical utility, and overuse of imaging tests.11⇓⇓⇓–15 Studies that have explored patient perspective are consistent with our study, identifying PCOs such as emotions (eg, anxiety and relief), physical risks, knowledge gains, and ability to manage disease.6,16 In our study, PCPs cited varying comfort with uncertainty. Previous research suggests clinicians use imaging as a tool to reduce return visits or to make a correct and definitive diagnosis.13,17 Vis et al18 found that gynecologists feared patients could become dependent on testing by constantly seeking reassurance. Reassurance overall was viewed positively but in our study concerns about false reassurance showed potential negative consequences.
Lack of time was raised as a major barrier to communication. Although 2 recent studies support this finding, one found that good communication is not necessarily time consuming.13,14 Patients report that providers are their most common and preferred source for medical information.19 However, neither PCPs nor patients are fully knowledgeable about all the risks and benefits of testing.20 Improving provider knowledge, and their ability to communicate that knowledge, could help reduce unnecessary imaging testing.
This study is a novel investigation of patient outcomes from the provider perspective, further confirming that tests themselves are associated with outcomes above and beyond impacts on treatment choices. PCPs reported general observations, suggesting applicability to a broad range of primary care scenarios. However, studies in other clinical settings and specialties might identify different outcomes. It is possible PCPs preferentially recall noteworthy over routine clinical situations, potentially impacting the generalizability of our findings. Qualitative analysis may be limited by the research team's perspective and biases may exist from the convenience sampling methods.
PCPs are aware of outcomes of importance to patients; however, communication of potential risks and benefits of tests related to these outcomes is limited by inadequate information and time pressures. Our findings suggest that PCPs need access to comprehensive evaluations of tests including PCOs, and tools to more effectively communicate this information. To facilitate more patient-centered decision making, research on methods for efficiently assessing and reporting patient-centered risks and benefits of imaging tests in comparative effectiveness research is needed.
Acknowledgments
The authors acknowledge the support and contributions of the PROD Study Team—a body of stakeholders, study site champions and coordinators, and researchers. We would also like to acknowledge Jessica Cruz for her assistance with data cleaning, as well as our participants whose time and stories made this work possible.
Notes
This article was externally peer reviewed.
Funding: The Patient-Centered Outcomes Research Institute (Grant “Patient-Centered Research for Standards of Outcomes in Diagnostic Tests (PROD)”) funded this study. This work was also supported through a Patient-Centered Outcomes Research Institute (PCORI) Program Award (ME-1503-29245). All statements in this report, including its findings and conclusions, are solely those of the authors and do not necessarily represent the views of the Patient-Centered Outcomes Research Institute (PCORI), its Board of Governors or Methodology Committee. This study was also supported by the National Center for Advancing Translational Sciences of the National Institutes of Health under Award UL1 TR002319. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
Conflict of interest: none declared.
To see this article online, please go to: http://jabfm.org/content/32/3/392.full.
- Received for publication September 25, 2018.
- Revision received January 15, 2019.
- Accepted for publication January 31, 2019.
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