Doctor shopping before and after a visit to a paediatric emergency department

Acute bronchiolitis in Switzerland - Current management and comparison over the last two decades

BACKGROUND

Although international guidelines and Cochrane reviews emphasize that therapies do not alter the natural course of acute viral bronchiolitis (AVB), they are still prescribed frequently. This survey evaluated self-reported management of AVB by Swiss pediatricians in 2019 and compared it with previous surveys.

METHODS

We performed a cross-sectional online survey of all board-certified pediatricians in Switzerland in November 2019 and compared the reported use of therapies with that reported in the 2001 and 2006 surveys. We used multivariable ordered logistic regression to assess factors associated with reported prescription of bronchodilators, corticosteroids, antibiotics, and physiotherapy.

RESULTS

Among 1618 contacted board-certified pediatricians, 884 returned the questionnaires (55% response rate). After exclusions were applied, 679 were included in the final analysis. Pediatricians working in primary care reported using therapeutics more frequently than those working in a hospital setting, either always or sometimes: bronchodilators 53% versus 38%, corticosteroids 37% versus 23%, and antibiotics 39% versus 22%. The opposite occurred with physiotherapy: 53% reported prescribing it in hospital and 44% in primary care. There was an overall decrease in the prescription of therapeutics and interventions for AVB from 2001 to 2019. The proportion who reported "always" prescribing corticosteroids decreased from 71% to 2% in primary care, and of those "always" prescribing bronchodilators from 55% to 1% in hospitals.

CONCLUSION

Although we observed a significant decrease since 2001, more effort is required to reduce the use of unnecessary therapies in children with AVB.

Information-seeking behavior of female doctor shoppers: results from an interview study

Purpose

This study aims to explore the information-seeking behavior of female patients engaged in doctor shopping. An investigation was conducted on the following aspects: the reasons for doctor-shopping behavior (DSB), patients’ information needs and sources, patients’ use of the obtained information and the degree of satisfaction with the information collected.

Design/methodology/approach

In-depth interviews were conducted in this study. In total, 30 female participants who lived or worked in the Taipei metropolitan area, Taiwan, were recruited.

Findings

Dissatisfaction with treatment, confirmation of illness conditions, inconvenient treatment locations and hours and dissatisfaction with doctor’s attitude were the main reasons for DSB. Family members, friends, the internet and mass media were sources of information for participants when they sought second and successive doctors. In most cases, the degree of satisfaction toward the obtained information increased after each visit to a doctor during the doctor-shopping journey. However, not all participants shared information with doctors. The participants suggested that detailed explanations provided by doctors and better communication with doctors may reduce the occurrence of doctor shopping.

Originality/value

The findings of this study help medical personnel better understand DSB. The findings revealed the significance of information to patients and indicated that the information collected during doctor shopping is beneficial for patients.

Second opinions, multiple physician appointments, and overlapping prescriptions in the paediatric population: A systematic literature review

OBJECTIVES

Doctor shopping, double doctoring, and overlapping prescriptions are often used as synonyms for multiple physician appointments in the same disease episode. Such behaviours translate into poor patient satisfaction and patient-doctor communication as well as abuse or misuse of drugs, increasing health care costs and resulting in negative health consequences. This systematic review of the literature was conducted to identify factors that drive doctor-shopping behaviour in children's caregivers.

METHODS

The search was conducted in PubMed and grey literature and was based on the following search terms: included doctor or physician shopping, drug seeking, double doctoring, children, and combinations of those. Overall, 500 records were identified, of which 11 were selected for qualitative synthesis. Data extracted considered definitions of doctor shopping, co-morbidities, and target population characteristics.

RESULTS

Definitions of doctor shopping were inconsistent. The frequency of doctor shopping was high for acute illnesses and ranged from 53% in children with a fever in Hong Kong to 18% at an emergency department in Canada. The incidence of this phenomenon was low when taking into account addictive drugs and was rated at 0.02% to 0.3% in the full paediatric population. This phenomenon was more prevalent in children younger than 1 year, in children with attention-deficit hyperactivity disorder (ADHD) and co-morbid psychiatric conditions, and in those whose caregivers themselves had psychiatric conditions. It was more frequent in cases with an acute disease (eg, fever, gastroenteritis, and urinary tract infection) than a chronic disease (eg, asthma).

CONCLUSIONS

The knowledge about doctor shopping by children's caregivers is limited, despite that this is a frequent behaviour. There is a need for further research covering a broader range of diseases. The causes and consequences of doctor shopping should be sought as well to investigate its relation to health care regulations and possibility to reduce unnecessary medical resource utilization.

Impacts of doctor-shopping behavior on diabetic patients' health: A retrospective longitudinal study in Taiwan

The aim of this study was to clarify the relationship between doctor-shopping behavior and clinical conditions, and to clearly outline the effects of both the number of clinic visits and the number of doctor changes on patients' health conditions. Data from January 1, 2000 to December 31, 2004 was collected from the National Health Insurance Research Database in Taiwan. After randomly selecting one million people, we extracted 5-year longitudinal data, about the number of clinic visits, number of doctor changes, and changes in self-health status for each patient with diabetes over the age of 18. We developed a relationship among the variables by using the generalized estimating equation. The results revealed that the number of clinic visits on the change of health status is a U curve, suggesting that health condition could be optimal with an appropriate number of clinic visits. The effect of the number of doctor changes is linearly correlated with health deterioration. The results suggest that disease conditions can only be controlled with an adequate number of clinic visits. Excessively frequent clinic visits are not only unfavorable to patients' health status but are also wasteful of limited medical resources. For diabetic mellitus patients, the more they change doctors, the worse their health status. All of these results are important for patients to stay healthy and to save medical resources.

Is healthy children surveillance being duplicated by family physicians and paediatricians? A cross-sectional study in Portugal

OBJECTIVES

To determine if children attend the family physician (FP) or the FP/paediatrician for their surveillance medical appointments, as well as analyse the variables associated with the parents' choice between the two physicians.

DESIGN

Cross-sectional study.

SETTING

Public, semiprivate and private kindergartens in the city of Vila Nova de Famalicão (Portugal).

PARTICIPANTS

Parents of children aged 6 years or less without chronic diseases, enrolled in the selected kindergartens.

MAIN OUTCOME MEASURES

Proportion of children attending the FP or FP/paediatrician for their surveillance appointments; association between the chosen physician and sociodemographic and household variables (parents' age, educational level, professional situation and marital status; household net income; number of children; the child's age; presence of private health insurance), assessment of the parents' perception of clinical knowledge and accessibility regarding the FP and the paediatrician.

RESULTS

A total of 697 children were included in the analysis: 30.6% attended only the FP and 69.4% attended both the FP and the paediatrician. Using a Poisson regression, the mother's age (PR=1.02, 95% CI 1.00 to 1.03), higher educational level (prevalence ratio (PR=1.15, 95% CI 1.00 to 1.33), private health insurance (PR=1.30, 95% CI 1.15 to 1.46), number of children (PR=0.86, 95% CI 0.78 to 0.94) and the child's age (PR=0.95, 95% CI 0.91 to 0.98) were statistically associated with attending both the FP and the paediatrician; parents of children who attended only FP rated the FP with a higher accessibility and knowledge mean score than those who consulted both physicians (2.91vs2.38, P<0.001, and 4.11vs3.85, P<0.001).

CONCLUSIONS

Our data show that 70% of our sample simultaneously attended an FP and a paediatrician. FPs are equally qualified to provide medical care to healthy children but this information is not properly transmitted to the general population.

Children's toothache is becoming everybody's business: where do parents go when their children have oral pain in London, England? A cross-sectional analysis

OBJECTIVES

To assess the number of parents who visited community pharmacies in London seeking pain medications for their children's pain and specifically for oral pain, to identify which health services parents contacted before their pharmacy visit and to estimate the cost to the National Health Service (NHS) when children with oral pain who visit pharmacies also see health professionals outside dentistry.

DESIGN

A cross-sectional study.

SETTING

1862 pharmacies in London in November 2016-January 2017.

PARTICIPANTS

Parents, carers and adolescents purchasing over-the-counter pain medications or collecting pain prescriptions for children (0-19 years).

BRIEF INTERVENTION

A survey administered by pharmacy staff to participants and a guidance pack.

MAIN OUTCOME MEASURES

The number of parents who visited pharmacies seeking pain medications for their children's pain and oral pain and the number of parents who contacted health professionals outside dentistry before their pharmacy visit. Estimated costs of visits by children with oral pain to health professionals outside dentistry.

RESULTS

One in two (951) pharmacies participated collecting information from 6915 parents seeking pain medications for their children. The majority (65%) of parents sought pain medications to relieve their children's oral pain. Only 30% of children with oral pain had seen a dentist before the pharmacy visit, while 28% of children had seen between one and four different health professionals. The cost to the NHS of children contacting health professionals outside dentistry was £36 573, extrapolated to an annual cost of £373 288. Replicating these findings across all pharmacies in England could mean that the NHS spends an estimated £2.3 million annually when children with oral pain inappropriately use multiple health services.

CONCLUSION

Most parents who visited pharmacies for children's pain medications in London sought pain medications for children's oral pain. Children's inappropriate contact with multiple health services when they have oral pain adds significant costs to the NHS.

Second Medical Opinion: Utilization Rates and Characteristics of Seekers in a General Population

BACKGROUND

Second opinion (SO) is common in medical practice and can reduce unnecessary risks and costs. To date, there is no population-based estimation of how many people seek SOs and what the characteristics of second-opinion seekers are.

OBJECTIVES

To estimate how many people seek SOs, and what the characteristics of second-opinion seekers are.

METHODS

We conducted both a medical records analysis (n=1,392,907) and a cross-sectional national telephone survey with a representative sample of the general Israeli population (n=848, response rate=62%). In the medical records analysis, we linked consultations with specialists at community secondary care and private consultations using claims data. We developed a time-sensitive algorithm that identified potential SO instances. In both methods, we predicted the characteristics of second-opinion seekers using multivariate logistic regressions.

RESULTS

The medical records analysis and the survey findings were highly consistent, and showed that about sixth (14.9% in the medical records vs. 17.2% in the survey) of a general population sought a SO, mostly from orthopedic surgeons. Women, native-born, and established immigrants, people living in central urban areas or close to central urban areas, people with chronic conditions, and those who perceived their health status as not very good, were more likely to seek SOs than others.

CONCLUSIONS

A considerable amount of people sought a SO. Certain patient profiles tended to seek SOs more than others. Such utilization patterns are important to devise policy regarding SOs, due to their implications on expenditure, policy, clinical outcomes, and patient satisfaction.

"Seeing a doctor is just like having a date": a qualitative study on doctor shopping among overactive bladder patients in Hong Kong

Background

Although having a regular primary care provider is noted to be beneficial to health, doctor shopping has been documented as a common treatment seeking behavior among chronically ill patients in different countries. However, little research has been conducted into the reasons behind doctor shopping behavior among patients with overactive bladder, and even less into how this behavior relates to these patients’ illness and social experiences, perceptions, and cultural practices. Therefore, this study examines overactive bladder patients to investigate the reasons behind doctor shopping behavior.

Methods

My study takes a qualitative approach, conducting 30 semi-structured individual interviews, with 30 overactive bladder patients in Hong Kong.

Results

My study found six primary themes that influenced doctor shopping behavior: lack of perceived need, convenience, work-provided medical insurance, unpleasant experiences with doctors, searching for a match doctor, and switching between biomedicine and traditional Chinese medicine. Besides the perceptual factors, participants’ social environment, illness experiences, personal cultural preference, and cultural beliefs also intertwined to generate their doctor shopping behavior. Due to the low perceived need for a regular personal primary care physician, environmental factors such as time, locational convenience, and work-provided medical insurance became decisive in doctor shopping behavior. Patients’ unpleasant illness experiences, stemming from a lack of understanding among many primary care doctors about overactive bladder, contributed to participants’ sense of mismatch with these doctors, which induced them to shop for another doctor.

Conclusions

Overactive bladder is a chronic bladder condition with very limited treatment outcome. Although patients with overactive bladder often require specialty urology treatment, it is usually beneficial for the patients to receive continuous, coordinated, comprehensive, and patient-centered support from their primary care providers. Primary care doctors’ understanding on patients with overactive bladder with empathetic attitudes is important to reduce the motivations of doctor shopping behavior among these patients.

Doctor shopping: a phenomenon of many themes

Doctor shopping is defined as seeing multiple treatment providers, either during a single illness episode or to procure prescription medications illicitly. According to the available literature, prevalence rates of doctor shopping vary widely, from 6.3 to 56 percent. However, this variability is partially attributable to research methodology, including the study definition of doctor shopping as well as the patient sample. The reasons for doctor shopping are varied. Some patient explanations for this phenomenon relate to clinician factors, such as inconvenient office hours or locations, long waiting times, personal characteristics or qualities of the provider, and/or insufficient communication time between the patient and clinician. Some patient explanations relate to personal factors and include both illness factors (e.g., symptom persistence, lack of understanding or nonacceptance of the diagnosis or treatment) as well as psychological factors (e.g., somatization, prescription drug-seeking). Importantly, not all doctor shopping is driven by suspect motivations. Being aware of these various patient justifications for doctor shopping is important in understanding and managing these challenging patients in the clinical setting, whether they emerge in psychiatric or primary care environments.

Study on doctor shopping behavior: insight from patients with upper respiratory tract infection in Taiwan

OBJECTIVES

Based on the actual medical records of ambulatory care visits, this study analyzed patients' healthcare seeking behavior and doctor shopping behavior (DSB), and investigated the underlying factors and the impact on the depletion of the healthcare resources for health policy makers to build a better health delivery system.

METHODS

Among a cohort comprised of 200,000 patients randomly chosen from the National Health Insurance Research Database of Taiwan in 2004, only the patients seeking ambulatory care visits for upper respiratory tract infection (URI) were analyzed.

RESULTS

Among the 45,951 URI patients, 2875 of them exhibited DSB (prevalence 6.3%). The DSB showed a reverse U-shaped relationship with the patient age (the highest DSB in age 18-34 years). The episodes of the URI had a negative impact on the DSB. The odds ratios of gender and the frequency of consultation versus DSB were 1.10 and 4.72, respectively, and the depletion of days of medication and repeat prescription increased with doctor shopping.

CONCLUSIONS

Health education to raise DSB awareness is necessary, especially for female's age 18-34 years. Implementing a proper referral system with efficient data exchange, setting up control parameters in the IC cards, and strengthening the integrated care plan could reduce the unnecessary waste of the healthcare resources.

Prevalence and determinants of pharmacy shopping behaviour

BACKGROUND AND OBJECTIVE

Discontinuity of care bears the risk of medication errors and poor clinical outcomes. Little is known about the continuity of care related to pharmacies. Therefore, we studied the prevalence and determinants of pharmacy shopping behaviour in the Netherlands.

METHODS

Beneficiaries from a Dutch pharmacy claims database who had visited two or more pharmacies in 2001 were indicated as 'shoppers' (n = 45 805). A random sample was taken from all the other beneficiaries who had received at least one prescription: 'non-shoppers' (n = 45 805). Shoppers were classified as light (all patients who visited more than one pharmacy at least once in 2001, except for patients defined as heavy or moderate shoppers), moderate (visited 3 or 4 pharmacies and had proportion of prescriptions elsewhere >10% and number of prescriptions elsewhere >10) or heavy (visited 5 or more pharmacies and had proportion of prescriptions elsewhere >10% and number of prescriptions elsewhere >10). Determinants of shopping behaviour were investigated as well as the association between any dispensing of Anatomical Therapeutic Chemical (ATC) classes of drugs and this behaviour.

RESULTS

10.8% beneficiaries were identified as shoppers: 98.8%'light shoppers', 1.0%'moderate shoppers' and 0.2%'heavy shoppers'. Female gender [odds ratio (OR)(adj) 1.2; 95% confidence interval (CI) 1.1-1.2], younger age (OR(adj) 1.7; 95%CI 1.7-1.8), the use of > or =3 drugs (OR(adj) 2.9; 95%CI 2.8-3.0) and visiting different kind of prescribers (OR(adj) 2.4; 95%CI 2.4-2.5) were associated with shopping behaviour. Shoppers more frequently received at least one prescription for systemic anti-infectives (51.7% vs. 30.8%; OR 2.4; 95%Cl 2.3-2.5) and for nervous system drugs (46.2% vs. 29.3%; OR 2.1; 95%Cl 2.0-2.1).

CONCLUSIONS

Pharmacy shopping behaviour is limited in the Netherlands. However, it may put the patient at risk for unintentional problems, such as drug-drug interactions with anti-infectives. A small proportion of patients exhibit possibly intentional shopping behaviour with psychotropic drugs.

Unremitting health-care-utilization outcomes of tertiary rehabilitation of patients with chronic musculoskeletal disorders

BACKGROUND

Unremitting health-care-seeking behaviors have only infrequently been addressed in the literature as an outcome of treatment for chronic disabling work-related musculoskeletal disorders. The limited research has never focused on the patient as the "driver" of health-care utilization, to our knowledge. As a result, little attention has been paid to the differences between treated patients who seek additional health care from a new provider and those who do not. The purpose of this project was to examine the demographic and socioeconomic outcome variables that characterize patients with a chronic disabling work-related musculoskeletal disorder who pursue additional health-care services from a new provider following the completion of a tertiary rehabilitation treatment program. A prospective comparison cohort design was employed to assess characteristics and outcomes of these patients, all of whom were treated with the same interdisciplinary protocol.

METHODS

A cohort of 1316 patients who had been consecutively treated with a rehabilitation program for functional restoration was divided into two groups on the basis of whether they had sought treatment from a new health-care provider in the year following completion of treatment. Group 0 (966 patients) did not visit a new health-care provider for treatment of their original occupational injury, and Group 1 (350 patients) visited a new provider on at least one occasion. A structured clinical interview to assess socioeconomic outcomes was carried out one year after discharge from the treatment program; this interview addressed pain, health-care utilization, work status, recurrent injury, and whether the Workers' Compensation case had been closed.

RESULTS

The percentage of Group-0 patients who had undergone pre-rehabilitation surgery was significantly lower than the percentage of Group-1 patients who had done so (12% compared with 21%, odds ratio = 1.9 [95% confidence interval = 1.3, 2.7]; p < 0.001). One year after treatment, 90% of the Group-0 patients had returned to work compared with only 78% of the Group-1 patients (odds ratio = 2.6 [95% confidence interval, 1.9, 3.6]; p < 0.001). Similarly, 88% of the Group-0 patients were still working at one year compared with only 62% of the patients in Group 1 (odds ratio = 4.5 [95% confidence interval, 3.3, 6.0]; p < 0.001). Whereas 96% of the Group-0 patients had resolved all related legal and/or financial disputes by one year, only 77% of the Group-1 patients had done so (odds ratio = 6.9 [95% confidence interval, 4.5, 10.5]; p < 0.001). Only a negligible percentage (0.4%) of the patients in Group 0 had undergone a new operation at the site of the original injury, whereas 12% of the Group-1 patients had done so (odds ratio = 31.0 [95% confidence interval, 11.0, 87.3]; p < 0.001). When the above outcome variables were analyzed by dividing Group 1 according to the number of visits to a new service provider, there was a trend for poorer socioeconomic outcomes to be associated with an increasing number of health-care visits.

CONCLUSIONS

To our knowledge, the present study represents the first large-scale examination of patients with a chronic disabling work-related musculoskeletal disorder who persist in seeking health-care following the completion of tertiary rehabilitation. The results demonstrate that about 25% of patients with a chronic disabling work-related musculoskeletal disorder pursue new health-care services after completing a course of treatment, and this subgroup accounts for a significant proportion of lost worker productivity, unremitting disability payments, and excess health-care consumption.

LEVEL OF EVIDENCE

Prognostic study, Level I-1 (prospective study). See Instructions to Authors for a complete description of levels of evidence.