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首页> 美国卫生研究院文献>British Medical Journal >Importance of patient pressure and perceived pressure and perceived medical need for investigations referral and prescribing in primary care: nested observational study
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Importance of patient pressure and perceived pressure and perceived medical need for investigations referral and prescribing in primary care: nested observational study

机译：初级保健中患者压力感知压力和感知医疗需求对调查转诊和开处方的重要性：嵌套观察研究

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>Objective To assess how pressures from patients on doctors in the consultation contribute to referral and investigation.>Design Observational study nested within a randomised controlled trial.>Setting Five general practices in three settings in the United Kingdom.>Participants 847 consecutive patients, aged 16-80 years.>Main outcomes measures Patient preferences and doctors' perception of patient pressure and medical need.>Results Perceived medical need was the strongest independent predictor of all behaviours and confounded all other predictors. The doctors thought, however, there was no or only a slight indication for medical need among a significant minority of those who were examined (89/580, 15%), received a prescription (74/394, 19%), or were referred (27/125, 22%) and almost half of those investigated (99/216, 46%). After controlling for patient preference, medical need, and clustering by doctor, doctors' perceptions of patient pressure were strongly associated with prescribing (adjusted odds ratio 2.87, 95% confidence interval 1.16 to 7.08) and even more strongly associated with examination (4.38, 1.24 to 15.5), referral (10.72, 2.08 to 55.3), and investigation (3.18, 1.31 to 7.70). In all cases, doctors' perception of patient pressure was a stronger predictor than patients' preferences. Controlling for randomisation group, mean consultation time, or patient variables did not alter estimates or inferences.>Conclusions Doctors' behaviour in the consultation is most strongly associated with perceived medical need of the patient, which strongly confounds other predictors. However, a significant minority of examining, prescribing, and referral, and almost half of investigations, are still thought by the doctor to be slightly needed or not needed at all, and perceived patient pressure is a strong independent predictor of all doctor behaviours. To limit unnecessary resource use and iatrogenesis, when management decisions are not thought to be medically needed, doctors need to directly ask patients about their expectations.
机译：>目的以评估咨询中患者对医生的压力如何有助于转诊和调查。>设计观察性研究嵌套在随机对照试验中。>设置英国在三种情况下的五种常规做法。>参与者连续847位患者，年龄16-80岁。>主要结局指标患者的喜好以及医生对患者压力和医疗的看法>结果。感知到的医疗需求是所有行为的最强独立预测因素，并且混淆了所有其他预测因素。但是，医生认为，在接受检查的极少数人中（89 / 580，15％），没有处方或仅有轻微迹象表明需要医疗，或者接受过处方（74 / 394，19％）或被转诊。 （27 / 125，22％）和几乎一半的受访者（99 / 216，46％）。在控制了患者的偏好，医疗需求和医生的聚类之后，医生对患者压力的看法与处方密切相关（调整后的优势比为2.87，95％置信区间1.16至7.08），与检查的相关性更强（4.38、1.24）至15.5），引荐（10.72、2.08至55.3）和调查（3.18、1.31至7.70）。在所有情况下，医生对患者压力的感知是比患者偏好更强的预测指标。控制随机分组，平均会诊时间或患者变量不会改变估计或推论。>结论医生在会诊中的行为与患者的医疗需求密切相关，这严重混淆了其他预测因素。但是，医生仍然认为很少有检查，开处方和转诊以及几乎一半的检查是必要的或根本不需要的，并且感知到的患者压力是所有医生行为的有力独立预测因素。为了限制不必要的资源使用和医源性，当认为在医疗上不需要管理决策时，医生需要直接询问患者他们的期望。

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