Association of treatment and outcomes of doctor-shopping behavior in patients with hepatocellular carcinoma

Decision Paralysis: Recognition and Patient-Centered Discourse

Decision paralysis (DP) can be defined as a patient's inability to commit to a physician and/or initiate appropriate treatment for their condition. An incessant search for greater physician opinions often leads to treatment delay, disease progression, and initiation of care at more advanced stages. Despite the harms associated with DP, a dearth of research on the issue remains. There are no guidelines that assist in both recognition and rectification of DP, leaving patients with chronic illnesses and diagnoses without well-characterized treatment algorithms especially vulnerable. This paper analyzes why patients are inclined toward DP and the clinical implications. Review of the literature affirms that the patient-physician relationship holds considerable influence; physicians identifying DP can improve therapeutic outcomes for their patients. Using these findings, we then propose a framework for broaching this topic with a method that supports patients while respecting their autonomy. A practical approach to both recognition and patient-centered discourse is introduced, providing a foundation for physicians to host these conversations and understand their patients' perspectives. This approach toward recognition and discourse on DP holds clinical importance, given that there is a paucity of established guidance. A future uniform approach may generate optimal patient care recommendations, which will hold far-reaching impact on both the patient-physician relationship and overall patient outcomes.

Trend of lung cancer surgery, hospital selection, and survival between 2005 and 2016 in South Korea

Background

Studies on the clinical implication of hospital selection for patients with lung cancer are few. Therefore, this study aimed to analyze 2005–2016 data from the Korean national database to assess annual trends of lung cancer surgery and clinical outcomes according to hospital selection.

Methods

Data of 212 554 patients with lung cancer who underwent upfront surgery were screened. Trends according to sex, age, residence, and income were examined. Descriptive statistics were performed, and p_trend values were estimated. The association between survival and hospital selection was assessed using the log‐rank test. A multivariate Cox regression analysis was also performed.

Results

A total of 49 021 patients were included in this study. Surgery was prevalent among men, patients aged 61–75 years, capital area residents, and high‐income patients. However, with the increasing rate of surgery among women, patients aged ≥76 years, city residents, and middle‐income patients, the current distribution of lung cancer surgery could change. The rate of lobectomy among these groups increased. All patients, except those in capital areas, preferred a hospital outside their area of residence (HOR); the number of patients with this tendency also increased. However, this trend was not observed among low‐income patients and those aged ≥76 years. There were significant differences in survival according to hospital selection.

Conclusions

The trend of lung cancer surgery is changing. The current medical system is effective in providing lobectomy for patients including women, aged ≥76 years, city residents, and middle‐income. Increasing tendency to choose an HOR requires further study.

Can diabetes patients seeking a second hospital get better care? Results from nested case-control study

This study investigates the effects of the number of medical institutions visited on risk of death. This study conducted a nested case-control design using the National Health Insurance Service-Senior database from 2002 to 2013. Cases were defined as those with death among outpatients who had first diagnosis of diabetes mellitus (E10-E14) after entry into the base cohort and controls were selected by incidence density sampling and matched to cases based on age, and sex. Our main results were presented by conditional logistic regression for nested case-controls design. Of total 55,558 final study samples, there were 9,313 (16.8%) cases and 46,245 (83.2%) controls. With an increase by one point in the number of hospitals per medical utilization, risk of death significantly increased by 4.1% (odds ratio (OR): 1.041, 95% confidence interval [CI]: 1.039-1.043). In both medical utilization and number of hospitals, those with high medical utilization (OR: 1.065, 95% CI: 1.059-1.070) and number of hospitals (OR: 1.049, 95% CI: 1.041-1.058) for risk of death were significantly higher than those with low medical utilization (OR: 1.040, 95% CI: 1.037-1.043) and number of hospitals (OR: 1.029, 95% CI: 1.027-1.032), respectively. The number of medical institution visited was significantly associated with risk of death. Therefore, diabetics should be warned about the potential of risk of death incurred from excessive access to medical utilizations.

Characteristics of doctor-shoppers: a systematic literature review

Objective: Doctor-shopping has significant consequences for patients and payers and can indicate misuse of drugs, polypharmacy, less continuity of care, and increased medical expenses. This study reviewed the literature describing doctor-shoppers in the adult population. Methods: A systematic literature review was performed in PubMed and supplemented by a Google search of grey literature. Overall, 2885 records were identified; 43 papers served as a source of definition of a doctor-shopper, disease, treatment, patient characteristics, patient special needs, country. Results: Definitions of doctor-shopping were heterogeneous. Overall, 40% of studies examined the use of opioids, antidepressants, or psychoactive drugs, while the others focused on chronic or frequent diseases. Most studies were conducted in countries with easy access to healthcare resources (USA, France, Taiwan, Hong Kong). The prevalence of doctor-shopping ranged from 0.5% among opioid users in the USA to 25% of patients registered at general practices in Japan. Comorbidities, active substance abuse, greater distance from healthcare facility, younger age, longer disease and poor patient satisfaction increased doctor-shopping. Conclusions: Knowing the characteristics of doctor-shoppers may help identify such patients and reduce the associated waste of medical resources, but concerns about the misuse of drugs or healthcare resources should not prevent proper disease management.

Patient-Driven Second Opinions in Oncology: A Systematic Review

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.

The impact of continuity of care on emergency room use in a health care system without referral management: an instrumental variable approach

PURPOSE

The purpose of the study was to determine whether continuity of care (COC) is beneficial in national health care systems without referral management by controlling for endogeneity of COC.

METHODS

We used National Health Insurance (Taiwan) claims data from 2008, encompassing approximately 23 million people, to determine whether COC is associated with reduced emergency room (ER) use by hypertension and diabetic patients in 2009. We used an instrumental variable approach to account for endogeneity associated with patients' COC levels.

RESULTS

After controlling for endogeneity, the marginal effect of COC on ER use probability when the COC score increased from 0 to 1 was 7.6% (P < .001) and 14.8% (P < .001) for hypertension and diabetic patients, respectively.

CONCLUSIONS

We determined that COC is more effective for reducing ER use than are models that assume that COC is exogenous. It has been argued that in many countries, health care systems without referral management encourage physician shopping and hinder physician-patient communication. However, there are benefits to disease-specific COC. Because current estimations have failed to take endogeneity biases into account, COC is more effective than is currently assumed.

Volume-outcome associations after major hepatectomy for hepatocellular carcinoma: a nationwide Taiwan study

OBJECTIVE

The objective of this study was to explore volume-outcome associations after major hepatectomy for hepatocellular carcinoma (HCC).

METHODS

This population-based cohort study retrospectively analyzed 23,107 major hepatectomies for HCC patients from 1998 to 2009. Relationships between hospital/surgeon volume and patient outcome were analyzed by propensity score matching (PSM). Five-year overall survival (OS) was estimated by Kaplan-Meier method, and differences were compared by log-rank test.

RESULTS

The mean length of stay (LOS) after major hepatectomy was 18.1 days, and the mean hospital cost was US$5,088.2. After PSM, the mean OS in high- and low-volume hospitals was 71.1 months (standard deviation (SD) 0.7 months) and 68.6 months (SD 0.6 months), respectively; the mean OS in high- and low-volume surgeons was 78.5 months (SD 0.7 months) and 66.9 months (SD 0.7 months), respectively. The PSM analysis showed that treatment by high-volume hospitals and treatment by high-volume surgeons were both associated with significantly shorter LOS, lower hospital cost, and longer survival compared to their low-volume counterparts (P < 0.001).

CONCLUSIONS

The results of this nationwide study support the regionalization of HCC treatment by hospital volume and by surgeon volume. High surgeon volume revealed both short- and long-term benefits. The applicability of PSM in volume-outcome analysis may also be confirmed.

Patterns of nonemergent visits to different healthcare facilities on the same day: a nationwide analysis in Taiwan

Doctor shopping is a common phenomenon in many countries. However, patterns of switching healthcare facilities on the same day were little known. The data were obtained from the longitudinal cohort datasets (LHID2010) of Taiwan's National Health Insurance Research Database in 2010. Of 1,000,000 persons of the cohort with 13,276,928 nonemergent visits, 185,347 patients had visited different healthcare facilities within one day, with a total of 672,478 visits and 337,260 switches between facilities in 329,073 patient-days. While 63.0% (n = 212,590) of all switches occurred between facilities of the same accreditation level, 14.1% (n = 47,664) moved from lower to higher level, and 22.8% (n = 77,006) moved in the opposite direction. In 33,689 switches, patients moved to the same specialty of another facility. In 48,324 switches, patients moved to another facility with the same diagnosis, and the most frequent diagnoses were diseases of the digestive system (11,148) and diseases of the respiratory system (10,393). In a densely populated country without strict referral regulation, a high percentage of Taiwanese people had the experience of visiting different healthcare facilities on the same day. The system of family physicians as personal doctors and gatekeepers to healthcare might ameliorate the harmful impact.

"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.