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Ferreira GE, Zadro J, Liu C, Harris IA, Maher CG. Second opinions for spinal surgery: a scoping review. BMC Health Serv Res 2022; 22:358. [PMID: 35300677 PMCID: PMC8932184 DOI: 10.1186/s12913-022-07771-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 03/10/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Second opinions have the goal of clarifying uncertainties around diagnosis or management, particularly when healthcare decisions are complex, unpleasant, and carry considerable risks. Second opinions might be particularly useful for people recommended surgery for their back pain as surgery has at best a limited role in the management of back pain. METHODS We conducted a scoping review. Two independent researchers screened PubMed, EMBASE, Cochrane CENTRAL and CINAHL from inception to May 6th, 2021. Studies of any design published in any language were eligible provided they described a second opinion intervention for people with spinal pain (low back or neck pain with or without radicular pain) either considering surgery or to whom surgery had been recommended. We assessed the methodological quality with the Downs & Black scale. Outcomes were: i) characteristics of second opinion services for people considering or who have been recommended spinal surgery, ii) agreement between first and second opinions in terms of diagnoses, need for surgery and type of surgery, iii) whether they reduce surgery and improve patient outcomes; and iv) the costs and healthcare use associated with these services. Outcomes were presented descriptively. RESULTS We screened 6341 records, read 27 full-texts, and included 12 studies (all observational; 11 had poor methodological quality; one had fair). Studies described patient, doctor, and insurance-initiated second opinion services. Diagnostic agreement between first and second opinions varied from 53 to 96%. Agreement for need for surgery between first and second opinions ranged from 0 to 83%. Second opinion services may reduce surgery rates in the short-term, but it is unclear whether these reductions are sustained in the long-term or if patients only delay surgery. Second opinion services may reduce costs and healthcare use (e.g. imaging), but might increase others (e.g. injections). CONCLUSIONS Second opinion services typically recommend less surgical treatments compared to first opinions and may reduce surgery rates in the short-term, but it is unclear whether these reductions are sustained in the long-term or if patients only delay surgery. There is a need for high-quality randomised trials to determine the value of second opinion services for reducing spinal surgery.
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Affiliation(s)
- Giovanni E Ferreira
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, Australia. .,School of Public Health, Faculty of Medicine and Health, The University of Sydney, PO Box M179, Missenden Road, Camperdown
- NSW
- , Sydney, New South Wales, 2050, Australia.
| | - Joshua Zadro
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, Australia.,School of Public Health, Faculty of Medicine and Health, The University of Sydney, PO Box M179, Missenden Road, Camperdown
- NSW
- , Sydney, New South Wales, 2050, Australia
| | - Chang Liu
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, Australia.,School of Public Health, Faculty of Medicine and Health, The University of Sydney, PO Box M179, Missenden Road, Camperdown
- NSW
- , Sydney, New South Wales, 2050, Australia
| | - Ian A Harris
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, Australia.,South Western Sydney Clinical School, Liverpool Hospital, The University of New South Wales, Sydney, New South Wales, Australia.,Ingham Institute of Applied Medical Research, Liverpool, Sydney, New South Wales, Australia
| | - Chris G Maher
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, Australia.,School of Public Health, Faculty of Medicine and Health, The University of Sydney, PO Box M179, Missenden Road, Camperdown
- NSW
- , Sydney, New South Wales, 2050, Australia
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Lehmann V, Smets EMA, de Jong M, de Vos FYF, Stouthard JM, Hillen MA. Patient-provider communication during second opinion consultations in oncology. PATIENT EDUCATION AND COUNSELING 2021; 104:2490-2497. [PMID: 33744055 DOI: 10.1016/j.pec.2021.03.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 02/11/2021] [Accepted: 03/06/2021] [Indexed: 06/12/2023]
Abstract
OBJECTIVE Providing a second opinion (SO) in oncology is complex, and communication during SOs remains poorly understood. This study aimed to systematically observe how patients and oncologists communicate about SO-specific topics (i.e., patient motivation, the referring oncologist, treatment transfer/back-referral), and how such communication affects patient satisfaction. METHODS A prospective mixed-methods study of cancer patients seeking a SO (N = 69) and consulting oncologists was conducted. Before the SO, patients reported their expected place of future treatment. Following the SO, patients' and oncologists' satisfaction was assessed. All SOs were audio-recorded. Absolute and relative duration of SO-specific talk were calculated and specific events (e.g., questions/utterances) were coded (incl. valence, explicitness). RESULTS SOs lasted 19-73 min, of which 3.7% was spent discussing motivations. Oncologists rarely explored patients' motivations. Talk about referring oncologists (12.5% of consultation) was mostly critical by patients (M = 43.0%), but positive/confirming by consulting oncologists (M = 73.5%). Although 22.2% of patients expected a treatment transfer, this topic (3.3% of consultation time) was rarely explicitly discussed. Patients who were referred back were significantly less satisfied (d = 0.85). CONCLUSION Patient-provider communication in oncological SOs appears insufficiently aligned. PRACTICE IMPLICATIONS Patients and oncologists need support to explicitly and productively communicate about SO-specific topics and to better manage expectations. Recommendations are provided.
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Affiliation(s)
- Vicky Lehmann
- Department of Medical Psychology, Amsterdam UMC, University of Amsterdam, Amsterdam Public Health, Amsterdam, the Netherlands.
| | - Ellen M A Smets
- Department of Medical Psychology, Amsterdam UMC, University of Amsterdam, Amsterdam Public Health, Amsterdam, the Netherlands.
| | - Maxime de Jong
- Department of Medical Psychology, Amsterdam UMC, University of Amsterdam, Amsterdam Public Health, Amsterdam, the Netherlands.
| | - Filip Y F de Vos
- Department of Medical Oncology, Cancer Center, University Medical Center Utrecht, Utrecht, the Netherlands.
| | | | - Marij A Hillen
- Department of Medical Psychology, Amsterdam UMC, University of Amsterdam, Amsterdam Public Health, Amsterdam, the Netherlands.
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Greenfield G, Shmueli L, Harvey A, Quezada-Yamamoto H, Davidovitch N, Pliskin JS, Rawaf S, Majeed A, Hayhoe B. Patient-initiated second medical consultations-patient characteristics and motivating factors, impact on care and satisfaction: a systematic review. BMJ Open 2021; 11:e044033. [PMID: 34561250 PMCID: PMC8475134 DOI: 10.1136/bmjopen-2020-044033] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES To review the characteristics and motivations of patients seeking second opinions, and the impact of such opinions on patient management, satisfaction and cost effectiveness. DATA SOURCES Embase, Medline, PsycINFO and Health Management Information Consortium (HMIC) databases. STUDY DESIGN A systematic literature search was performed for terms related to second opinion and patient characteristics. Study quality was assessed using the National Institutes of Health Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies. DATA COLLECTION/EXTRACTION METHODS We included articles focused on patient-initiated second opinions, which provided quantitative data on their impact on diagnosis, treatment, prognosis or patient satisfaction, described the characteristics or motivating factors of patients who initiated a second opinion, or the cost-effectiveness of patient-initiated second opinions. PRINCIPAL FINDINGS Thirty-three articles were included in the review. 29 studies considered patient characteristics, 19 patient motivating factors, 10 patient satisfaction and 17 clinical agreement between the first and second opinion. Seeking a second opinion was more common in women, middle-age patients, more educated patients; and in people having a chronic condition, with higher income or socioeconomic status or living in central urban areas. Patients seeking a second opinion sought to gain more information or reassurance about their diagnosis or treatment. While many second opinions confirm the original diagnosis or treatment, discrepancies in opinions had a potential major impact on patient outcomes in up to 58% of cases. No studies reported on the cost effectiveness of patient initiated second opinions. CONCLUSIONS This review identified several demographic factors associated with seeking a second opinion, including age, gender, health status, and socioeconomic status. Differences in opinion received, and in the impact of change in opinion, varies significantly between medical specialties. More research is needed to understand the cost effectiveness of second opinions and identify patient groups most likely to benefit from second opinions.
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Affiliation(s)
- Geva Greenfield
- Primary Care and Public Health, School of Public Health, Imperial College London Department of Life Sciences, London, UK
| | - Liora Shmueli
- Department of Management, Bar-Ilan University, Ramat-Gan, Israel
| | - Amy Harvey
- Primary Care and Public Health, School of Public Health, Imperial College London Department of Life Sciences, London, UK
| | - Harumi Quezada-Yamamoto
- Primary Care and Public Health, School of Public Health, Imperial College London Department of Life Sciences, London, UK
| | - Nadav Davidovitch
- Health Policy and Management, School of Public Health, Ben Gurion University of the Negev, Beer-Sheva, Israel
| | - Joseph S Pliskin
- Health Policy and Management, School of Public Health, Ben Gurion University of the Negev, Beer-Sheva, Israel
| | - Salman Rawaf
- Primary Care and Public Health, School of Public Health, Imperial College London Department of Life Sciences, London, UK
| | - Azeem Majeed
- Primary Care and Public Health, School of Public Health, Imperial College London Department of Life Sciences, London, UK
| | - Benedict Hayhoe
- Primary Care and Public Health, School of Public Health, Imperial College London Department of Life Sciences, London, UK
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Halasy M, Shafrin J. When Should You Trust Your Doctor? Establishing a Theoretical Model to Evaluate the Value of Second Opinion Visits. Mayo Clin Proc Innov Qual Outcomes 2021; 5:502-510. [PMID: 33997646 PMCID: PMC8105538 DOI: 10.1016/j.mayocpiqo.2021.01.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
In order to produce a mathematical model for better understanding of the benefits and utilization of second opinions and to understand the contradiction between the value of second opinions and their perceived underuse, we developed an expected utility theory model to quantify their value. We use a case-based example to find types of biases that could affect second opinions. Although the baseline expected utility theory model presented assumes providers are rational, we relax this and discuss the implications for how these alternative specifications alter predicted use. We found that second opinions are valuable when diagnostic accuracy is variable across physicians or access to high-quality care is restricted. In a stylized simulation example in which about half (50.1%) of diagnoses were incorrect, receipt of 1 second opinion reduced the error rate to 25.8% and receipt of 2 second opinions reduced the error rate to 16.0%. After incorporating potential biases into the model, the value of second opinions increases only when aversion to changing the initial diagnosis is greater than aversion to correcting a mistake. Additionally, this model reveals that second opinions have value even when diagnostic accuracy is perfect. Further, when financial incentives differ from the incentives of the initial consult, a second opinion offers patients a reasonable bound of their treatment options. To conclude, we identify numerous reasons for underuse of second opinions. Specifically, value depends on the degree of diagnostic uncertainty, presence of behavioral biases, and variation in local compensation regimes. Despite their value, recent trends could actually decrease the value of second opinions.
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Affiliation(s)
- Michael Halasy
- College of Medicine, Spine Center, Mayo Clinic, Rochester, MN
| | - Jason Shafrin
- Center for Healthcare Economics and Policy, FTI Consulting, Los Angeles, CA
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Second medical opinion in oncological setting. Crit Rev Oncol Hematol 2021; 160:103282. [PMID: 33675905 DOI: 10.1016/j.critrevonc.2021.103282] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Revised: 01/23/2021] [Accepted: 02/27/2021] [Indexed: 11/20/2022] Open
Abstract
Oncological patients increasingly require second medical opinions to feel more likely confident with their oncologists and treatments, although this could lead to wrong opinions and delay in the start of treatments. Second opinions can be required also by physicians to obtain advices, especially in case of rare tumors. The request of new opinions is documented in radiology and pathology settings too, with not negligible discrepancy rate. Conversely, the role in general medical/surgical conditions has not been well established. Literature is poor of studies relative to second opinions or they are more focused on patient's motivations. For these reasons, AIOM (Italian Association of Medical Oncology) and AIOM Foundation faced this topic during the 7th Annual Meeting on Ethics in Oncology (Ragusa, 4-5 t h May 2018). In this position paper we report reasons, limits, advantages and outcomes of second medical opinion and the respective Decalogue in the oncological setting.
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Expert Reliability in Legal Proceedings: "Eeny, Meeny, Miny, Moe, With Which Expert Should We Go?". Sci Justice 2020; 61:37-46. [PMID: 33357826 DOI: 10.1016/j.scijus.2020.09.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 09/07/2020] [Accepted: 09/20/2020] [Indexed: 11/21/2022]
Abstract
Between Expert Reliability refers to the extent to which different experts examining identical evidence make the same observations and reach the same conclusions. Some areas of expert decision making have been shown to entail questions with relatively low Between Expert Reliability, but the disagreement between experts is not always communicated to the legal actors forming decisions on the basis of the expert evidence. In this paper, we discuss the issues of Between Expert Reliability in legal proceedings, using forensic age estimations as a case study. Across national as well international jurisdictions, there is large variation in which experts are hired to conduct age estimations as well as the methods they use. Simultaneously, age estimations can be fully decisive for outcomes e.g. in asylum law and criminal law. Using datasets obtained from the Swedish legal context, we identify that radiologists and odontologists examining knees or teeth images to estimate age seem to disagree within their own disciplines (radiologist 1 v. radiologist 2 or odontologist 1 v. odontologist 2) as well as across different disciplines (radiologist v. odontologist) relatively often. This may have large implications e.g. in cases where only one expert from the respective field is involved. The paper discusses appropriate ways for legal actors to deal with the possibility of lacking Between Expert Reliability. This is indeed a challenging task provided that legal actors are legal experts but not necessarily scientific experts.
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Abstract
BACKGROUND Patients seeking second opinions are a challenge for the colorectal cancer provider because of complexity, failed therapeutic relationship with another provider, need for reassurance, and desire for exploration of treatment options. OBJECTIVE The purpose of this study was to describe the patient and treatment characteristics of patients seeking initial and second opinions in colorectal cancer care at a multidisciplinary colorectal cancer clinic. DESIGN This was a retrospective cohort study. SETTINGS A prospectively collected clinical registry of a multidisciplinary colorectal cancer clinic was included. PATIENTS The study included patients with colon or rectal cancer seen from 2012 to 2017. MAIN OUTCOME MEASURES Data were analyzed for initial versus second opinion and demographic and clinical characteristics. RESULTS Of 1711 patients with colorectal cancer, 1008 (58.9%) sought an initial opinion and 700 (40.9%) sought a second opinion. As compared with initial-opinion patients, second-opinion patients were more likely to have stage IV disease (OR = 1.94 (95% CI, 1.47-2.58)), recurrent disease (OR = 1.67 (95% CI, 1.13-2.46)), and be ages 40 to 49 years (OR = 1.47 (95% CI, 1.02-2.12)). Initial- and second-opinion cohorts were similar in terms of sex, race, and proportion of colon versus rectal cancer. Among second-opinion patients, 246 (35%) transitioned their care to the multidisciplinary colorectal cancer clinic. LIMITATIONS We were unable to capture the final treatment plan for those patients who did not transfer care to the multidisciplinary colorectal cancer clinic. CONCLUSIONS Patients seeking a second opinion represent a unique subset of patients with colorectal cancer. In general, they are younger and more likely to have stage IV or recurrent disease than patients seeking an initial opinion. Although transfer of care to a multidisciplinary colorectal cancer clinic after second opinion is lower than for initial consultations, multidisciplinary colorectal cancer clinics provide an important role for patients with complex disease characteristics and treatment needs. See Video Abstract at http://links.lww.com/DCR/B192. CARACTERíSTICAS DE LOS PACIENTES QUE BUSCAN UNA SEGUNDA OPINIóN EN CLíNICAS MULTIDISCIPLINARIAS ESPECIALIZADAS EN CáNCER COLORECTAL: Los pacientes que buscan una segunda opinión son un desafío para el médico que trata el cáncer colorrectal debido a la complejidad de la situación, a la relación terapéutica fallida con otro especialista, a la necesidad de tranquilidad y el deseo de explorar otras opciones del tratamiento.El describir las características y el tratamiento de los pacientes que buscan opiniones iniciales y secundarias en la atención del cáncer colorrectal en una clínica especializada de manera multidisciplinaria en cáncer colorrectal.Este es un estudio de cohortes retrospectivo.Registro clínico de casos obtenidos prospectivamente en una clínica especializada de manera multidisciplinaria en cáncer colorrectal.Todos aquellos pacientes con cáncer de colon o recto examinados entre 2012-2017.Se analizaron los datos obtenidos en la opinión inicial y se compararon con la segunda opinión, se revisaron tanto sus características demográficas como clínicas.De 1711 pacientes con cáncer colorrectal, 1008 (58.9%) buscaron una opinión inicial, 700 (40.9%) buscaron una segunda opinión. En comparación con los pacientes de opinión inicial, los pacientes de segunda opinión presentaron más probabilidades de tener enfermedad en estadio IV (OR 1.94, IC 95% 1.47-2.58), enfermedad recurrente (OR 1.67, IC 95% 1.13-2.46) y tener edades entre 40 y 49 (O 1.47, IC 95% 1.02-2.12). Las cohortes iniciales y de segunda opinión fueron similares en términos de género, raza y proporción del cáncer de colon versus cáncer de recto. Entre los pacientes de segunda opinión, 246 (35%) transfirieron su tratamiento hacia una clínica multidisplinaria especializada en cáncer colorrectal.No se obtuvieron los planes del tratamiento final de aquellos pacientes que no transfirieron sus cuidados hacia una la clínica especializada en cáncer colorrectal.Los pacientes que buscan una segunda opinión representan un subconjunto único de personas con cáncer colorrectal. En general, son más jóvenes y tienen más probabilidades de tener enfermedad en estadio IV o recurrente, con relación a aquellos pacientes que buscan una opinión inicial. Aunque la transferencia de los cuidados hacia una clínica multidisciplinaria especializada en cáncer colorrectal después de una segunda opinión es menor que para las consultas iniciales. Las clínicas multidisciplinarias especializadas en cáncer colorrectal juegan un papel importante con los pacientes que tienen características complejas de enfermedad y necesidades particulares en el tratamiento. Consulte Video Resumen en http://links.lww.com/DCR/B192. (Traducción-Dr Xavier Delgadillo).
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Weyerstraß J, Prediger B, Neugebauer E, Pieper D. Results of a patient-oriented second opinion program in Germany shows a high discrepancy between initial therapy recommendation and second opinion. BMC Health Serv Res 2020; 20:237. [PMID: 32192450 PMCID: PMC7083019 DOI: 10.1186/s12913-020-5060-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Accepted: 02/28/2020] [Indexed: 12/20/2022] Open
Abstract
Background As of 2015, second opinions are legally implemented in Germany. However, empirical results from German second opinion programs are lacking. The aim of this study was to examine several aspects within a population of a German second opinion program. Methods Study population consisted of patients who sought a second opinion in the period from August 2011 to December 2016. Multivariate logistic regression and ANOVA were used to examine differences in patient characteristics, differentiated by agreement of initial therapy recommendation and second opinion. Follow-up points for patient satisfaction and HRQoL were defined at 1, 3 and 6 months after obtaining the second opinion. Results Total number of patients who sought a second opinion was 1414. Most common indications concerned the knee (37.3%), spine (27.3%), hip (11.5%) and shoulder (10.1%). The independent specialists did not confirm the initial therapy recommendations in two out of three cases. The type of indication influenced the agreement between initial therapy recommendation and the second opinion significantly (p = 0.035). The second opinion and the offered service was highly valued by the patients (89%). Conclusions The second opinion offers patients the possibility to confirm a medical indication independently and support patients in their decision making process. Reasons for the large discrepancy between initial therapy recommendation and second opinion should be addressed in future research.
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Affiliation(s)
- Jan Weyerstraß
- University of Witten/Herdecke, Alfred-Herrhausen-Straße 50, Witten, 58455, Germany.
| | - Barbara Prediger
- Institute for Research in Operative Medicine (IFOM), Interim Head: Prof. Dr. Rolf Lefering, Chair of Surgical Research, Faculty of Health, School of Medicine, University of Witten/Herdecke, Ostmerheimer Str. 200, 51109, Cologne, Germany
| | - Edmund Neugebauer
- Institute for Research in Operative Medicine (IFOM), Interim Head: Prof. Dr. Rolf Lefering, Chair of Surgical Research, Faculty of Health, School of Medicine, University of Witten/Herdecke, Ostmerheimer Str. 200, 51109, Cologne, Germany.,Brandenburg Medical School Theodor Fontane (MHB), Brandenburg, Germany
| | - Dawid Pieper
- Institute for Research in Operative Medicine (IFOM), Interim Head: Prof. Dr. Rolf Lefering, Chair of Surgical Research, Faculty of Health, School of Medicine, University of Witten/Herdecke, Ostmerheimer Str. 200, 51109, Cologne, Germany.
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Larcher V, Brierley J. Second medical opinions in paediatric practice; proposals for a framework for best practice. Arch Dis Child 2020; 105:213-215. [PMID: 31320359 DOI: 10.1136/archdischild-2019-317223] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 07/01/2019] [Accepted: 07/05/2019] [Indexed: 11/04/2022]
Affiliation(s)
- Vic Larcher
- Paediatric Bioethics Centre, National Institute for Health Research Great Ormond Street Hospital Biomedical Research Centre, London, UK
| | - Joe Brierley
- Paediatric Bioethics Centre, National Institute for Health Research Great Ormond Street Hospital Biomedical Research Centre, London, UK
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Shmueli L, Shmueli E, Pliskin JS, Balicer RD, Davidovitch N, Hekselman I, Greenfield G. Second opinion utilization by healthcare insurance type in a mixed private-public healthcare system: a population-based study. BMJ Open 2019; 9:e025673. [PMID: 31352409 PMCID: PMC6661653 DOI: 10.1136/bmjopen-2018-025673] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
OBJECTIVES To evaluate the utilisation (overall and by specialty) and the characteristics of second-opinion seekers by insurance type (either health fund or supplementary insurance) in a mixed private-public healthcare. DESIGN An observational study. SETTING Secondary care visits provided by a large public health fund and a large supplementary health insurance in Israel. PARTICIPANTS The entire sample included 1 392 907 patients aged 21 years and above who visited at least one specialist over an 18 months period, either in the secondary care or privately via the supplementary insurance. OUTCOMES MEASURES An algorithm was developed to identify potential second-opinion instances in the dataset using visits and claims data. Multivariate logistic regression was used to identify characteristics of second-opinion seekers by the type of insurance they used. RESULTS 143 371 (13%) out of 1 080 892 patients who had supplementary insurance sought a single second opinion, mostly from orthopaedic surgeons. Relatively to patients who sought second opinion via the supplementary insurance, second-opinion seekers via the health fund tended to be females (OR=1.2, 95% CI 1.17 to 1.23), of age 40-59 years (OR=1.36, 95% CI 1.31 to 1.42) and with chronic conditions (OR=1.13, 95% CI 1.08 to 1.18). In contrast, second-opinion seekers via the supplementary insurance tended to be native-born and established immigrants (OR=0.79, 95% CI 0.76 to 0.84), in a high socioeconomic level (OR=0.39, 95% CI 0.37 to 0. 4) and living in central areas (OR=0.88, 95% CI 0.85 to 0.9). CONCLUSIONS Certain patient profiles tended to seek second opinions via the supplementary insurance more than others. People from the centre of the country and with a high socioeconomic status tended to do so, as medical specialists tend to reside in central urban areas. Further research is recommended to examine the availability of medical specialists by specialty and residence.
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Affiliation(s)
- Liora Shmueli
- Department of Management, Bar Ilan University, Ramat Gan, Israel
| | - Erez Shmueli
- Department of Industrial Engineering, Tel Aviv University, Tel Aviv, Israel
| | - Joseph S Pliskin
- Department of Industrial Engineering and Management, Ben-Gurion University of the Negev, Beer-Sheva, Israel
- Department of Health Systems Management, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Ran D Balicer
- Epidemiology, Ben-Gurion University, Tel Aviv, Israel
- Clalit Research Institute, Tel Aviv, Israel
| | - Nadav Davidovitch
- Department of Health Systems Management, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Igal Hekselman
- Clalit Mushlam Health Insurance, Bnei Brak, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Geva Greenfield
- Department of Primary Care & Public Health, Imperial College London, London, UK
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Shmueli L, Davidovitch N, Pliskin JS, Hekselman I, Balicer RD, Greenfield G. Reasons, perceived outcomes and characteristics of second-opinion seekers: are there differences in private vs. public settings? BMC Health Serv Res 2019; 19:238. [PMID: 31014323 PMCID: PMC6480844 DOI: 10.1186/s12913-019-4067-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Accepted: 04/05/2019] [Indexed: 01/29/2023] Open
Abstract
Background In most countries, patients can get a second opinion (SO) through public or private healthcare systems. There is lack of data on SO utilization in private vs. public settings. We aim to evaluate the characteristics of people seeking SOs in private vs. public settings, to evaluate their reasons for seeking a SO from a private physician and to compare the perceived outcomes of SOs given in a private system vs. a public system. Methods A cross-sectional national telephone survey, using representative sample of the general Israeli population (n = 848, response rate = 62%). SO utilization was defined as seeking an additional clinical opinion from a specialist within the same specialty, on the same medical concern. We modeled SO utilization in a public system vs. a private system by patient characteristics using a multivariate logistic regression model. Results 214 of 339 respondents who obtained a SO during the study period, did so in a private practice (63.1%). The main reason for seeking a SO from a private physician rather than a physician in the public system was the assumption that private physicians are more professional (45.7%). However, respondents who obtained a private SO were neither more satisfied from the SO (p = 0.45), nor felt improvement in their perceived clinical outcomes after the SO (p = 0.37). Low self-reported income group, immigrants (immigrated to Israel after 1989) and religious people tended to seek SOs from the public system more than others. Conclusions The main reason for seeking a SO from private physicians was the assumption that they are more professional. However, there were no differences in satisfaction from the SO nor perceived clinical improvement. As most of SOs are sought in the private system, patient misconceptions about the private market superiority may lead to ineffective resource usage and increase inequalities in access to SOs. Ways to improve public services should be considered to reduce health inequalities.
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Affiliation(s)
- Liora Shmueli
- Department of Health Systems Management, Ben-Gurion University of the Negev, P.O. Box 653, 84105, Beer-Sheva, Israel
| | - Nadav Davidovitch
- Department of Health Systems Management, Ben-Gurion University of the Negev, P.O. Box 653, 84105, Beer-Sheva, Israel
| | - Joseph S Pliskin
- Department of Health Systems Management, Ben-Gurion University of the Negev, P.O. Box 653, 84105, Beer-Sheva, Israel.,Department of Industrial Engineering and Management, Ben-Gurion University of the Negev, P.O. Box 653, 84105, Beer-Sheva, Israel
| | - Igal Hekselman
- Clalit Mushlam Health Insurance Systems, Clalit Health Services, 1 Ben Gurion, 5120149, Bnei Brak, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Ran D Balicer
- Clalit Research Institute, Clalit Health Services, 101 Arlozorov, 62098, Tel-Aviv, Israel
| | - Geva Greenfield
- Department of Primary Care and Public Health, School of Public Health, Imperial College London, The Reynolds Building, St. Dunstan's Road, London, W6 8RP, UK.
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Abstract
BACKGROUND Although second opinions are rather restricted to the surgical disciplines, they have become more and more important to the health system in the last 20 years. The demand has been triggered by rising health costs and the economization of the field. The Internet has also made a considerable contribution to the demand for patient-initiated second opinions. Given these developments, it is surprising that second opinions have not become more important in the field of psychiatry. This article highlights the special situation of second opinions in psychiatry, discusses possible barriers to the adoption of second opinions in psychiatry, and the potential for greater use of second opinions in this field. OBJECTIVE In psychiatry, second opinions have been neglected by the typical drivers of innovations in health care, including insurers and other commercial drivers as well as psychiatrists and patients themselves. This review identifies current barriers to widespread adoption of second opinions in psychiatric practice, discusses the benefits of second opinions that have been demonstrated in other disciplines, and outlines the potential gains to be realized through use of second opinions in psychiatry. METHODS Literature in the area was reviewed through a search of the main medical databases. This literature review was supported by in-depth interviews with health care personnel and insurers. CONCLUSIONS Second opinions are rarely obtained in psychiatry and there is little literature on this subject. The stigmatization of psychiatric disorders and patients and the uniqueness of the patient-doctor relationship in psychiatry, especially in psychotherapeutic care, may pose considerable obstacles to the use of second opinions in this field. In addition, more stakeholders, such as social workers, government agencies and regulators, health care and disability insurers, and social security agencies, are involved in the mental health compared with the somatic health sector, which may make it more difficult to achieve a coordinated approach in psychiatric care. However, we have found no convincingly good reason why second opinions have not been at least discussed in psychiatry. Psychiatry could benefit from ongoing discussions concerning the outcomes of second opinions in other medical disciplines.
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Shmueli L, Davidovitch N, Pliskin JS, Balicer RD, Hekselman I, Greenfield G. Seeking a second medical opinion: composition, reasons and perceived outcomes in Israel. Isr J Health Policy Res 2017; 6:67. [PMID: 29221461 PMCID: PMC5721599 DOI: 10.1186/s13584-017-0191-y] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2015] [Accepted: 11/23/2017] [Indexed: 11/10/2022] Open
Abstract
Background Seeking a second-opinion (SO) is a common clinical practice that can optimize treatment and reduce unnecessary procedures and risks. We aim to characterize the composition of the population of SO seekers, their reasons for seeking a SO and choosing a specific physician, and their perceived outcomes following the SO. Methods A cross-sectional national telephone survey, using a representative sample of the general Israeli population (n = 848, response rate = 62%). SO utilization was defined as seeking an additional clinical opinion from a specialist within the same specialty, for the same medical concern. We describe the characteristics of respondents who obtained SOs, their reasons for doing so and their perceived outcomes: (1) Satisfaction with the SO; (2) Experiencing health improvement after receiving a SO; (3) A difference in the diagnosis or treatment suggested in the first opinions and the second opinions; (4) Preference of the SO over the first one. Results Most of the respondents who sought a SO (n = 344) were above 60 years old, secular, living with a partner, perceived their income to be above average and their health status to be not so good. For the patients who utilized SOs, orthopedic surgeons were sought out more than any other medical professional.Reasons for seeking a SO included doubts about diagnosis or treatment (38%), search for a sub-specialty expert (19%) and dissatisfaction with communication (19%). SO seekers most frequently chose a specific specialist based on a recommendation from a friend or a relative (33%). About half of the SO seekers also searched for information on the internet. Most of the respondents who sought a SO mentioned that they were satisfied with it (84%), felt health improvement (77%), mentioned that there was a difference between the diagnosis or treatment between the first opinion and the SO (56%) and preferred the SO over the first one (91%). Conclusions Clinical uncertainty or dissatisfaction with patient-physician communication were the main reasons for seeking a SO. Policy makers should be aware that many patients choose a physician for a SO based on recommendations made outside the medical system. We recommend creating mechanisms that help patients in the complicated process of seeking a SO, suggest specialists who are suitable for the specific medical problem of the patient, and provide tools to reconcile discrepant opinions. Electronic supplementary material The online version of this article (10.1186/s13584-017-0191-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Liora Shmueli
- Department of Health Systems Management, Ben-Gurion University of the Negev, P.O. Box 653, 84105, Beer-Sheva, Israel.
| | - Nadav Davidovitch
- Department of Health Systems Management, Ben-Gurion University of the Negev, P.O. Box 653, 84105, Beer-Sheva, Israel
| | - Joseph S Pliskin
- Department of Health Systems Management, Ben-Gurion University of the Negev, P.O. Box 653, 84105, Beer-Sheva, Israel.,Department of Industrial Engineering and Management Ben-Gurion University of the Negev, P.O. Box 653, 84105, Beer-Sheva, Israel
| | - Ran D Balicer
- Clalit Research Institute, Clalit Health Services, 101 Arlozorov, 62098, Tel-Aviv, Israel
| | - Igal Hekselman
- Clalit Mushlam Health Insurance Systems, Clalit Health Services, 1 Ben Gurion, 5120149, Bnei Brak, Israel
| | - Geva Greenfield
- Department of Primary Care and Public Health, School of Public Health, Imperial College London, The Reynolds Building, St. Dunstan's Road, London, W6 8RP, UK
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Hillen MA, Medendorp NM, Daams JG, Smets EMA. Patient-Driven Second Opinions in Oncology: A Systematic Review. Oncologist 2017; 22:1197-1211. [PMID: 28606972 PMCID: PMC5634767 DOI: 10.1634/theoncologist.2016-0429] [Citation(s) in RCA: 64] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Accepted: 04/27/2017] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Although patient-driven second opinions are increasingly sought in oncology, the desirability of this trend remains unknown. Therefore, this systematic review assesses evidence on the motivation for and frequency of requests for second opinions and examines how they evolve and their consequences for oncological practice. MATERIALS AND METHODS Relevant databases were sought using the terms "cancer," "second opinion," and "self-initiated." Included were peer-reviewed articles that reported on patient-initiated second opinions within oncology. Selection, data extraction, and quality assessment were performed and discussed by two researchers. RESULTS Of the 25 included studies, the methodological designs were qualitative (n = 4), mixed (n = 1), or quantitative (n = 20). Study quality was rated high for 10 studies, moderate for eight, and low for seven studies. Reported rates of second opinion seeking ranged from 1%-88%. Higher education was most consistently related to seeking a second opinion. Patients' primary motivations were a perceived need for certainty or confirmation, a lack of trust, dissatisfaction with communication, and/or a need for more (personalized) information. Reported rates of diagnostic or therapeutic discrepancies between the first and second opinions ranged from 2%-51%. DISCUSSION Additional studies are required to further examine the medical, practical, and psychological consequences of second opinions for patients and oncologists. Future studies could compare the potential advantages and disadvantages of second opinion seeking, and might offer guidance to patients and physicians to better facilitate the second opinion process. Some practical recommendations are provided for oncologists to optimally discuss and conduct second opinions with their patients. The Oncologist 2017;22:1197-1211 IMPLICATIONS FOR PRACTICE: Although cancer patients increasingly seek a second opinion, the benefits of this process remain unclear. Results of this systematic review suggest that the available studies on this topic are highly variable in both methodology and quality. Moreover, reported rates for a second opinion (1%-88%) as well as for disagreement between the first and second opinion (2%-51%) range widely. The primary motivations of patients are a need for certainty, lack of trust, dissatisfaction with communication, and/or a need for more (personalized) information. Additional research should evaluate how unnecessary second opinions might be avoided. Practical suggestions are provided for oncologists to optimize second opinions.
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Affiliation(s)
- Marij A Hillen
- Department of Medical Psychology, Amsterdam, The Netherlands
| | | | - Joost G Daams
- Medical Library, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Ellen M A Smets
- Department of Medical Psychology, Amsterdam, The Netherlands
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Second Medical Opinion: Utilization Rates and Characteristics of Seekers in a General Population. Med Care 2017; 54:921-8. [PMID: 27213545 DOI: 10.1097/mlr.0000000000000567] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
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.
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Radhakrishnan A, Grande D, Mitra N, Bekelman J, Stillson C, Pollack CE. Second opinions from urologists for prostate cancer: Who gets them, why, and their link to treatment. Cancer 2016; 123:1027-1034. [PMID: 28263389 DOI: 10.1002/cncr.30412] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2016] [Revised: 09/29/2016] [Accepted: 10/03/2016] [Indexed: 11/08/2022]
Abstract
BACKGROUND Cancer patients are encouraged to obtain second opinions before starting treatment. Little is known about men with localized prostate cancer who seek second opinions, the reasons why, and the association with treatment and quality of care. METHODS We surveyed men who were diagnosed with localized prostate cancer in the greater Philadelphia area from 2012 to 2014. Men were asked if they obtained a second opinion from a urologist, and the reasons why. We used multivariable logistic regression models to evaluate the relationship between second opinions and definitive prostate cancer treatment and perceived quality of care. RESULTS A total of 2386 men responded to the survey (adjusted response rate, 51.1%). After applying exclusion criteria, the final analytic cohort included 2365 respondents. Of these, 40% obtained second opinions, most commonly because they wanted more information about their cancer (50.8%) and wanted to be seen by the best doctor (46.3%). Overall, obtaining second opinions was not associated with definitive treatment or perceived quality of cancer care. Men who sought second opinions because they were dissatisfied with their initial urologist were less likely to receive definitive treatment (odds ratio, 0.49; 95% confidence interval, 0.32-0.73), and men who wanted more information about treatment were less likely to report excellent quality of cancer care (odds ratio, 0.70; 95% confidence interval, 0.49-0.99) compared with men who did not receive a second opinion. CONCLUSIONS Although a large proportion of men with localized prostate cancer obtained a second opinion, the reasons for doing so were not associated with treatment choice or perceived quality of cancer care. Future study is needed to determine when second opinions contribute to increasing the value of cancer care. Cancer 2017;123:1027-34. © 2016 American Cancer Society.
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Affiliation(s)
- Archana Radhakrishnan
- Division of General Internal Medicine, Johns Hopkins University, Baltimore, Maryland
| | - David Grande
- Division of General Internal Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Nandita Mitra
- Department of Biostatistics and Epidemiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Justin Bekelman
- Department of Radiation Oncology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Christian Stillson
- Division of General Internal Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Craig Evan Pollack
- Division of General Internal Medicine, Johns Hopkins University, Baltimore, Maryland.,Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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Meyer AND, Singh H, Graber ML. Evaluation of outcomes from a national patient-initiated second-opinion program. Am J Med 2015; 128:1138.e25-33. [PMID: 25913850 DOI: 10.1016/j.amjmed.2015.04.020] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2015] [Revised: 03/03/2015] [Accepted: 04/01/2015] [Indexed: 01/05/2023]
Abstract
BACKGROUND We examined outcomes of patient-initiated second opinions provided by a national second-opinion program. METHODS We independently examined data collected from January 1, 2011 to December 31, 2012 from a second-opinion program (Best Doctors, Inc.) that allows employee-beneficiaries to request free second opinions. Clinical intake included ascertaining why patients sought second opinions and acquiring patients' complete medical records. Trained physicians summarized the cases; identified key, unresolved clinical questions; and forwarded the cases to expert specialists who provided independent assessments and recommendations. Second opinions were discussed with and returned to patients for review with their physicians. Nurses determined whether second opinions confirmed, clarified, or changed initial diagnoses and treatments, and physicians estimated their clinical impact. Patient satisfaction also was surveyed. RESULTS A total of 6791 patient-initiated second opinions were completed across medical specialties. Patients primarily sought second opinions for help choosing treatment options (41.3%) and for diagnostic concerns (34.8%). Second opinions often resulted in changes in diagnosis (14.8%), treatment (37.4%), or changes in both (10.6%). Clinical impact was estimated as moderate/major in 20.9% of cases for diagnosis and 30.7% of cases for treatment. Changes in diagnoses and/or treatments and clinical impact varied across medical specialties. In patients surveyed (n = 2683), most (94.7%) were satisfied with the experience, but fewer (61.2%) planned to follow the recommendations. CONCLUSIONS Patient-initiated second opinions led to recommended changes in diagnosis for about 15% and in treatment for about 37% of participants. Further evaluation is needed to determine whether this impacts clinical outcomes, such as the reduction of diagnosis and treatment errors.
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Affiliation(s)
- Ashley N D Meyer
- Houston Veterans Affairs Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, Tex; Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Tex.
| | - Hardeep Singh
- Houston Veterans Affairs Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, Tex; Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Tex
| | - Mark L Graber
- RTI International, Research Triangle Park, NC; SUNY Stony Brook School of Medicine, New York, NY
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18
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Payne VL, Singh H, Meyer AND, Levy L, Harrison D, Graber ML. Patient-initiated second opinions: systematic review of characteristics and impact on diagnosis, treatment, and satisfaction. Mayo Clin Proc 2014; 89:687-96. [PMID: 24797646 DOI: 10.1016/j.mayocp.2014.02.015] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2013] [Revised: 02/13/2014] [Accepted: 02/26/2014] [Indexed: 11/30/2022]
Abstract
The impact of second opinions on diagnosis in radiology and pathology is well documented; however, the value of patient-initiated second opinions for diagnosis and treatment in general medical practice is unknown. We conducted a systematic review of patient-initiated second opinions to assess their impact on clinical outcomes and patient satisfaction and to determine characteristics and motivating factors of patients who seek a second opinion. We searched PubMed, EMBASE, Cochrane, and Academic OneFile databases using Medical Subject Headings (MeSH) indexes and keyword searches. Search terms included referral and consultation, patient-initiated, patient preference, patient participation, second opinion, second review, and diagnosis. Multiple reviewers screened abstracts and articles to determine eligibility and extract data. We assessed risk of bias using the Cochrane Risk of Bias Tool and rated study quality using Cochrane's GRADE (Grades of Recommendation, Assessment, Development and Evaluation) approach. We screened 1342 abstracts and reviewed full text of 41 articles, identifying 7 articles that reported clinical agreement data and 10 that discussed patient characteristics, motivation, and satisfaction. We found that a second opinion typically confirms the original diagnosis or treatment regimen but that 90% of patients with poorly defined conditions remain undiagnosed. However, 10% to 62% of second opinions yield a major change in the diagnosis, treatment, or prognosis. A larger fraction of patients receive different advice on treatment than on diagnosis. Factors motivating a second opinion include diagnosis or treatment confirmation, dissatisfaction with a consultation, desire for more information, persistent symptoms, or treatment complications. Patients generally believed that second opinions were valuable. Second opinions can result in diagnostic and treatment differences. The literature on patient-initiated second opinions is limited, and the accuracy of the second opinion through follow-up is generally unknown. Standardized methods and outcome measures are needed to determine the value of second opinions, and the potential of second opinions to reduce diagnostic errors merits more rigorous evaluation.
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Affiliation(s)
- Velma L Payne
- Houston Veterans Affairs Health Services Research and Development Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, and Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, TX
| | - Hardeep Singh
- Houston Veterans Affairs Health Services Research and Development Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, and Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, TX
| | - Ashley N D Meyer
- Houston Veterans Affairs Health Services Research and Development Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, and Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, TX
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19
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The Role of the Surgical Second Opinion. Patient Saf Surg 2014. [DOI: 10.1007/978-1-4471-4369-7_12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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20
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Gologorsky D, Greenstein SH. Retrospective analysis of patients self-referred to comprehensive ophthalmology seeking second opinions. Clin Ophthalmol 2013; 7:1099-102. [PMID: 23807829 PMCID: PMC3685446 DOI: 10.2147/opth.s46448] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Patients choose to seek a second opinion in matters related to their health for a variety of reasons, and the total cost associated with these second opinion visits is estimated to be billions of dollars annually. Understanding the reasons behind second opinion self-referrals is key to improving patient satisfaction and reducing redundancy in delivered health care. This study represents a retrospective analysis of the records from a single provider at the Massachusetts Eye and Ear Infirmary (MEEI) Comprehensive Ophthalmology Service in order to determine the various reasons that patients self-refer to an ophthalmology clinic seeking second opinions. A total of 174 patients presenting for a second opinion were identified over a one-year period. Patients presented for second opinions for two primary reasons: 60% presented in order to seek a confirmation of a diagnosis from an outside ophthalmologist (54%) or optometrist (6%), and 40% presented due to a previous adverse experience with an outside provider, such as perceived treatment failure (26%), poor bedside manner (3%), distrust of the provider (5%), and poor provider communication skills (7%). This study strives to reiterate that the reduction of adverse patient experiences through effective communication of expected treatment options and outcomes, with a realistic time course of therapy, could significantly improve patient satisfaction and reduce costly second opinion visits.
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Okamoto S, Kawahara K, Okawa A, Tanaka Y. Values and risks of second opinion in Japan's universal health-care system. Health Expect 2013; 18:826-38. [PMID: 23409806 DOI: 10.1111/hex.12055] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/21/2013] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Second opinion (SO) is widely recognized in Japan, but we do not know how patients view and use SO. OBJECTIVES To investigate optimum seeking of SO in Japan's universal health-care system. DESIGN, PARTICIPANTS, AND METHODS Survey of patients at Tokyo Medical and Dental University Hospital. Of 365 responses, 67 had experienced SO with standardized protocol at SO Clinic; 82 had obtained SO elsewhere without instruction; 216 had never sought SO. MAIN OUTCOME MEASURES Views of values and risks of SO. RESULTS Second opinion patients with standardized protocol better understood their illness, treatment options, individualized plan, and uncertainty in medicine, and also reported improved decision making compared with SO patients without the protocol (P < 0.05). However, more than half of respondents misunderstood SO as a way to change doctors or treatment. Second opinion respondents (n = 149) had a propensity to request treatment changes (P < 0.1) and more than one-third (n = 82) did not tell SO doctor they were being treated by another doctor. The absolute majority of non-SO patients would seek SO for a serious illness but would hesitate to tell their doctors. DISCUSSION AND CONCLUSION Respondents recognized value of SO to improve understanding and decision making. This study also found risks in SO misuse which may be reinforced by Japan's cultural tendencies and universal health-care system. Our findings suggest steps to increase the benefit of SO: ensure involvement of original doctor, instruct patients about SO and help them organize their thinking before SO and facilitate patients' return to the treating doctor for discussion and decision making.
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Affiliation(s)
- Sawako Okamoto
- Division of Health Care Management and Planning, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Kazuo Kawahara
- Division of Health Care Management and Planning, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Atsushi Okawa
- Department of Orthopedic Surgery, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Yujiro Tanaka
- Department of Medical Education Research and Development, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
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Hsieh CI, Chung KP, Yang MC, Li TC. Association of treatment and outcomes of doctor-shopping behavior in patients with hepatocellular carcinoma. Patient Prefer Adherence 2013; 7:693-701. [PMID: 23874090 PMCID: PMC3713999 DOI: 10.2147/ppa.s43631] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND A variety of unfulfilled needs may trigger doctor-shopping behavior (DSB) in patients. In oncology, treatment results usually cause patients the most concern. This study investigated the association of DSB with active treatments received by patients with hepatocellular carcinoma (HCC) and outcomes. METHODS With approval from the institutional review board, all patients registered in the cancer database of a teaching hospital and diagnosed as having HCC by self-referral from outside hospitals or by in-house diagnosis were retrospectively identified. Patient data were then reviewed and analyzed via electronic medical records. RESULTS Hepatitis B carriers were significantly more likely than noncarriers to show first-time DSB. Recurrent disease was less likely to result in DSB than predicted. Patients from outside hospitals not receiving upfront first treatment after diagnosis were significantly more likely to show more frequent DSB than those receiving it. Male patients eligible for salvage treatment were less likely to have frequent occurrences of DSB than their female counterparts. Receiving first salvage treatment was not associated with more frequent DSB. Treatment recommendations offered in the study hospital did not influence patients' decisions to leave or stay. Only elderly patients (>70 years) were less likely to show DSB. CONCLUSION DSB can occur throughout the entire course of treatment for HCC for a variety of reasons. Active treatments, disease status, and patient characteristics all exerted an influence on DSB.
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Affiliation(s)
- Cheng-I Hsieh
- Division of Hematology and Oncology, Department of Internal Medicine, Taipei Medical University Hospital
- Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University
- Institute of Health Policy and Management, College of Public Health, National Taiwan University, Taipei
| | - Kuo-Piao Chung
- Institute of Health Policy and Management, College of Public Health, National Taiwan University, Taipei
- Correspondence: Kuo-Piao Chung Room 635, 17 Suchow Rd, Taipei, Taiwan 10052, People’s Republic of China, Tel +886 2 33668065, Fax 886 2 23581541, Email
| | - Ming-Chin Yang
- Institute of Health Policy and Management, College of Public Health, National Taiwan University, Taipei
| | - Tsai-Chung Li
- Graduate Institute of Biostatistics, College of Public Health, China Medical University
- Graduate Institute of Chinese Medicine Science, College of Chinese Medicine, China Medical University
- Department of Healthcare Administration, College of Health Science, Asia University, Taichung, Taiwan
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Do first opinions affect second opinions? J Gen Intern Med 2012; 27:1265-71. [PMID: 22539066 PMCID: PMC3445697 DOI: 10.1007/s11606-012-2056-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2011] [Revised: 01/11/2012] [Accepted: 03/07/2012] [Indexed: 10/28/2022]
Abstract
BACKGROUND Second medical opinions have become commonplace and even mandatory in some health-care systems, as variations in diagnosis, treatment or prognosis may emerge among physicians. OBJECTIVE To evaluate whether physicians' judgment is affected by another medical opinion given to a patient. DESIGN Orthopedic surgeons and neurologists filled out questionnaires presenting eight hypothetical clinical scenarios with suggested treatments. One group of physicians (in each specialty) was told what the other physician's opinion was (study group), and the other group was not told what it was (control group). PARTICIPANTS A convenience sample of 332 physicians in Israel: 172 orthopedic surgeons (45.9% of their population) and 160 neurologists (64.0% of their population). MEASUREMENTS Scoring was by choice of less or more interventional treatment in the scenarios. We used χ(2) tests and repeated measures ANOVA to compare these scores between the two groups. We also fitted a cumulative ordinal regression to account for the dependence within each physician's responses. RESULTS Orthopedic surgeons in the study group chose a more interventionist treatment when the other physician suggested an intervention than those in the control group [F (1, 170) =4.6, p=0.03; OR=1.437, 95% CI 1.115-1.852]. Evaluating this effect separately in each scenario showed that in four out of the eight scenarios, they chose a more interventional treatment when the other physician suggested an intervention (scenario 1, p=0.039; scenario 2, p<0.001; scenario 3, p=0.033; scenario 6, p<0.001). These effects were insignificant among the neurologists [F (1,158) =0.44, p=0.51; OR=1.087, 95% CI 0.811-1.458]. In both specialties there were no differences in responses by level of clinical experience [orthopedic surgeons: F (2, 166) =0.752, p=0.473; neurologists: F (2,154) =1.951, p=0.146]. CONCLUSIONS The exploratory survey showed that in some cases physicians' judgments may be affected by other physicians' opinions, but unaffected in other cases. Weighing previous opinions may yield a more informed clinical decision, yet physicians may be unintentionally influenced by previous opinions. Second opinion has the potential to improve the clinical decision-making processes, and mechanisms are needed to reconcile discrepant opinions.
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Patient–physician relationships in second opinion encounters – The physicians’ perspective. Soc Sci Med 2012; 75:1202-12. [DOI: 10.1016/j.socscimed.2012.05.026] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2011] [Revised: 05/17/2012] [Accepted: 05/20/2012] [Indexed: 11/23/2022]
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Greenfield G, Pliskin JS, Wientroub S, Davidovitch N. Orthopedic surgeons' and neurologists' attitudes towards second opinions in the Israeli healthcare system: a qualitative study. Isr J Health Policy Res 2012; 1:30. [PMID: 22913507 PMCID: PMC3441381 DOI: 10.1186/2045-4015-1-30] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2011] [Accepted: 06/18/2012] [Indexed: 11/15/2022] Open
Abstract
Background Second opinion is a treatment ratification tool that may critically influence diagnosis, treatment, and prognosis. Second opinions constitute one of the largest expenditures of the supplementary health insurance programs provided by the Israeli health funds. The scarcity of data on physicians’ attitudes toward second opinion motivated this study to explore those attitudes within the Israeli healthcare system. Methods We interviewed 35 orthopedic surgeons and neurologists in Israel and qualitatively analyzed the data using the Grounded Theory approach. Results As a common tool, second opinion reflects the broader context of the Israeli healthcare system, specifically tensions associated with health inequalities. We identified four issues: (1) inequalities between central and peripheral regions of Israel; (2) inequalities between private and public settings; (3) implementation gap between the right to a second opinion and whether it is covered by the National Health Insurance Law; and (4) tension between the authorities of physicians and religious leaders. The physicians mentioned that better mechanisms should be implemented for guiding patients to an appropriate consultant for a second opinion and for making an informed choice between the two opinions. Conclusions While all the physicians agreed on the importance of the second opinion as a tool, they raised concerns about the way it is provided and utilized. To be optimally implemented, second opinion should be institutionalized and regulated. The National Health Insurance Law should strive to provide the mechanisms to access second opinion as stipulated in the Patient’s Rights Law. Further studies are needed to assess the patients' perspectives.
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Affiliation(s)
- Geva Greenfield
- Department of Primary Care and Public Health, School of Public Health, Imperial College London, The Reynolds Building, St Dunstans Road, London, W6 8RP, UK.
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Tattersall MHN, Dear RF, Jansen J, Shepherd HL, J Devine R, G Horvath L, Boyer MJ. Second opinions in oncology: the experiences of patients attending the Sydney Cancer Centre. Med J Aust 2009; 191:209-12. [DOI: 10.5694/j.1326-5377.2009.tb02754.x] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2009] [Accepted: 05/31/2009] [Indexed: 11/17/2022]
Affiliation(s)
- Martin H N Tattersall
- Department of Cancer Medicine, University of Sydney, Sydney, NSW
- Department of Medical Oncology, Sydney Cancer Centre, Royal Prince Alfred Hospital, Sydney, NSW
| | - Rachel F Dear
- Department of Medicine and Centre for Medical Psychology and Evidence‐based Decision‐making, Central Clinical School, University of Sydney, Sydney, NSW
| | - Jesse Jansen
- Department of Cancer Medicine, University of Sydney, Sydney, NSW
- Department of Medicine and Centre for Medical Psychology and Evidence‐based Decision‐making, Central Clinical School, University of Sydney, Sydney, NSW
- NIVEL (Netherlands Institute for Health Services Research), Utrecht, Netherlands
| | - Heather L Shepherd
- Department of Medicine and Centre for Medical Psychology and Evidence‐based Decision‐making, Central Clinical School, University of Sydney, Sydney, NSW
| | - Rhonda J Devine
- Department of Medicine and Centre for Medical Psychology and Evidence‐based Decision‐making, Central Clinical School, University of Sydney, Sydney, NSW
| | - Lisa G Horvath
- Department of Medical Oncology, Sydney Cancer Centre, Royal Prince Alfred Hospital, Sydney, NSW
| | - Michael J Boyer
- Department of Medical Oncology, Sydney Cancer Centre, Royal Prince Alfred Hospital, Sydney, NSW
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Patients seeking second medical hematology/oncology opinions in the United States: a report of their demographics and disease processes. ACTA ACUST UNITED AC 2007. [DOI: 10.1016/s1548-5315(11)70075-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Wagner LS, Wagner TH. The effect of age on the use of health and self-care information: confronting the stereotype. THE GERONTOLOGIST 2003; 43:318-24. [PMID: 12810895 DOI: 10.1093/geront/43.3.318] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
PURPOSE Given stereotypes of older adults, there is the perception that older adults will not use health information technologies. One concern is that practitioners might shy away from providing older patients with health information, and in particular, computerized information. The study's primary objective was to evaluate whether a health information intervention had a differential effect for people of different ages. DESIGN AND METHODS Quasi-experimental survey data from an assessment of a communitywide informational intervention were used. People were asked about their use of medical reference books, telephone advice nurses, or computers for health information in the past few months. In total, 5,909 surveys were completed. RESULTS The data show that older adults were no less likely (and were sometimes more likely) to use health information as a result of the intervention than younger adults. For telephone advice nurses and computers, the effect of the intervention was not significantly different for the different age groups. Yet, compared with persons 18-29 years of age, those over the age of 65 had a 17-percentage point increase in using a self-care book. IMPLICATIONS We find convincing evidence to counter the stereotype that older adults are resistant to trying new health information technologies.
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Affiliation(s)
- Lisa Smith Wagner
- Department of Psychology, University of San Francisco, CA 94117, USA.
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29
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Jacobson JA. Keeping the Patient in the Loop: Ethical Issues in Outpatient Referral and Consultation. THE JOURNAL OF CLINICAL ETHICS 2002. [DOI: 10.1086/jce200213405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Flynn KE, Smith MA, Davis MK. From physician to consumer: the effectiveness of strategies to manage health care utilization. Med Care Res Rev 2002; 59:455-81. [PMID: 12508705 PMCID: PMC1635490 DOI: 10.1177/107755802237811] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Many strategies are commonly used to influence physician behavior in managed care organizations. This review examines the effectiveness of three mechanisms to influence physician behavior: financial incentives directed at providers or patients, policies/procedures for managing care, and the selection/education of both providers and patients. The authors reach three conclusions. First, all health care systems use financial incentives, but these mechanisms are shifting away from financial incentives directed at the physician to those directed at the consumer. Second, heavily procedural strategies such as utilization review and gatekeeping show some evidence of effectiveness but are highly unpopular due to their restrictions on physician and patient choice. Third, a future system built on consumer choice is contradicted by mechanisms that rely solely on narrow networks of providers or the education of physicians. If patients become the new locus of decision making in health care, provider-focused mechanisms to influence physician behavior will not disappear but are likely to decline in importance.
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Affiliation(s)
- Kathryn E. Flynn
- Department of Sociology, University of Wisconsin-Madison, 8128
Social Science Building, 1180 Observatory Drive, Madison, WI 53706-1393.
Telephone: (608) 263-4416 FAX: (608) 263-2820 E-mail:
| | - Maureen A. Smith
- Department of Population Health Sciences, University of
Wisconsin-Madison Medical School, 603 WARF Building, 610 Walnut Street, Madison,
WI 53705-2397. Telephone: (608) 262-4802 FAX: (608) 263-2820 E-mail:
| | - Margaret K. Davis
- Division of Health Services Research and Policy, University of
Minnesota School of Public Health, MMC 729, 420 Delaware Street SE, Minneapolis,
MN 55455-0392. Telephone: (612) 626-0696 FAX: (612) 626-4681 E-mail:
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31
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Benson WE, Regillo CD, Vander JF, Tasman W, Smith AF, Brown GC, Ho AC, McNamara JA. Patient-initiated second medical opinions: their necessity and economic cost. Retina 2002; 21:633-8. [PMID: 11756887 DOI: 10.1097/00006982-200112000-00011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE To assess the value of patient-initiated second medical opinions (SMO). METHODS The authors prospectively collected demographic data from 100 consecutive patients. The authors recorded major changes in the patients' care, such as inappropriate surgery recommended, inadequate treatment performed, and appropriate treatment not recommended. The authors also recorded costs incurred or saved by the patients and the third-party payers. RESULTS In nearly 15 of the cases, the authors had major disagreements with the initial diagnosis or management. Surgery had been recommended in 28 cases. They advised against it in nine. In 72 cases, no surgery had been recommended. They advised and performed it in five. The management of five other patients was not in accordance with that recommended by large clinical trials or was inadequately done. Including the consultation fees, surgery performed or advised against, retinal angiography, and ultrasonography, the 100 SMO cost third-party payers $12,426. If the authors subtract the cost of noncontroversial surgery they recommended and if the patients had paid the consultation fee and had brought along their fluorescein angiograms, third-party payers would have saved $4,079. CONCLUSION The savings SMO generated by eliminating unnecessary surgery resulted in improved patient care at minimal cost to third-party payers.
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Affiliation(s)
- W E Benson
- Retina Service of Wills Eye Hospital, Philadelphia, Pennsylvania, USA
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Clauson J, Hsieh YC, Acharya S, Rademaker AW, Morrow M. Results of the Lynn Sage Second-Opinion Program for local therapy in patients with breast carcinoma. Changes in management and determinants of where care is delivered. Cancer 2002; 94:889-94. [PMID: 11920455 DOI: 10.1002/cncr.10318] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND The treatment options of breast conservation therapy (BCT) and immediate reconstruction for patients with carcinoma of the breast have not been adopted widely. The objectives of this study were to determine how often a second opinion on the local therapy of breast carcinoma changed patient management and to identify factors predictive of remaining at the second-opinion site for therapy. METHODS Two hundred thirty-one patients with intraductal carcinoma or Stage I and II breast carcinoma were reviewed retrospectively. At the time of the second opinion, patients completed a questionnaire regarding their initial surgical opinion and the reason for seeking consultation. RESULTS Only 46% of patients had a complete discussion of treatment options prior to the second opinion. The second opinion changed management in 54 patients (20.3%). The most common finding was eligibility for BCT in patients who were offered only mastectomy. Definitive local therapy occurred at the second-opinion site in 65.8% of patients. The only predictors of remaining at the second-opinion site were insurance type (P = 0.008) and the patient's perception that options were not discussed at the initial opinion (P < 0.001). CONCLUSIONS Second opinions provide useful information to patients and may change the management of their disease. They result in significant patient capture for an institution.
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Affiliation(s)
- Jennifer Clauson
- Lynn Sage Breast Program, Northwestern University, Chicago, Illinois, USA
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