Denial of some patient requests, but not others, associated with decreased patient satisfaction, study finds

Denial of requests was associated with worse patient satisfaction for referrals, pain medications, other new medications, and lab tests, but not for antibiotics, radiology tests, or other tests.


Physician denial of patient requests for referrals, certain medications, and laboratory tests was associated with worse patient satisfaction, but denial of antibiotics or radiology was not, a recent observational study found.

From July 2015 to May 2016, researchers enrolled 1,141 adults (mean age, 45.6 years; 68.4% female) who made 1,319 outpatient visits to 56 family physicians at one Northern California academic health center. They measured patient satisfaction using six items from the Consumer Assessment of Healthcare Providers and Systems Clinician and Group Adult Visit Survey. They then used modeling to observe mean differences in patient satisfaction percentile associated with fulfillment or denial of the following request types: referral, pain medication, antibiotic, other new medication, lab test, radiology test, or other test. The models were adjusted for various patient characteristics, such as sociodemographics, weight, health status, personality, and worry over health.

Results were published online on Nov. 27 by JAMA Internal Medicine.

Overall, 897 of 1,319 visits (68.0%) included at least one request, and clinicians fulfilled 1,441 of 1,691 requests (85.2%). The most common requests were for lab tests (34.0%), followed by referrals (21.1%), pain medications (20.5%), other new medications (20.5%), radiology tests (11.6%), other tests (11.1%), and antibiotics (8.1%).

Compared with fulfillment of each request category, denial was associated with worse satisfaction for the following requests: referrals (adjusted mean percentile differences, −19.75; 95% CI, −30.75 to −8.74), pain medications (−10.72; 95% CI, −19.66 to −1.78), other new medications (−20.36; 95% CI, −29.54 to −11.18), and lab tests (−9.19; 95% CI, −17.50 to −0.87), respectively. Denied requests for antibiotics, radiology tests, or other tests were not significantly associated with lower patient satisfaction.

Limitations of the study include its single-center design and unmeasured contextual factors that may have influenced patient satisfaction. The study authors also noted that patients self-reported the fulfillment and denial of requests, so overreporting or underreporting may have occurred.

It is “no coincidence” that requests for antibiotics and imaging tests were not associated with lower patient satisfaction, according to an accompanying editor's note. “Through Choosing Wisely and other campaigns to reduce low-value care, substantial attention has been devoted to preparing physicians to avoid frequently requested, low-value care such as these,” the editor wrote. “We can train physicians to say no to other types of clinically inappropriate requests, while still reassuring patients and paying attention to their needs.”