Change in frequency of patient requests for diagnostic screening and interventions during primary care encounters from 1985 to 2014

Change in frequency of patient requests for diagnostic screening and interventions during primary... Abstract Background The reason why patients contact a care provider, the reason for encounter (RFE), reflects patients’ personal needs and expectations regarding medical care. RFEs can be symptoms or complaints, but can also be requests for diagnostic or therapeutic interventions. Objectives Over the past 30 years, we aim to analyse the frequency with which patients consult a GP to request an intervention, and to analyse the impact of these requests on the subsequent diagnostic process. Methods We included all patients with a request for diagnostics, medication prescription or referral from 1985 to 2014. We analysed the number of requests, granted requests and interventions originating from a request. We compared the final diagnosis (symptom or disease diagnosis) between patients with and without a request. Design and Setting This is a retrospective cohort study with data from Family Medicine Network, a Dutch primary healthcare registration network. Results Over time, patients more often present to their GP with a request for intervention. GPs are increasingly compliant with these requests. Patients presenting with a request for intervention are more likely to be diagnosed with a symptom rather than a disease. Conclusion This study provides insight into the changes in patients’ and GPs’ behaviour and patients’ influence on the medical process, and confirms the clinical relevance of the RFE. This study could support GPs in daily practice when deciding whether or not to grant a request. International Classification of Primary Care, patients’ request, primary health care, reason for encounter, symptom diagnosis Introduction To provide individualized care, GPs should be aware of the reason why the patient seeks medical care, the so-called reason for encounter (RFE). The RFE reflects the patients’ personal needs and expectations regarding medical care. The RFE is not influenced by interpretation of the care provider. Ignoring the RFE leads to a loss of important information and results in underestimating the healthcare needed for a patient (1–5). The RFE can be classified as a symptom (e.g. headache), a disease (e.g. migraine) or a request [e.g. referral (1)]. GPs’ compliance with patients’ requests is high: when patients ask for medication or a blood test, it is often performed (2–5). Being aware of the RFE improves the diagnostic process, which is an important task of GPs (6,7). A previous study identified six RFEs with a high predictive value for colorectal cancer [CRC (7)]. A couple of months prior to the diagnosis, patients presenting with tiredness, anaemia, abdominal pain, rectal bleeding, constipation or weight loss as RFE had a higher likelihood and odds ratio for CRC which may have high predictive power. The relation between patient’s RFE, diagnosis and GPs’ interventions provides more insight into the medical process. In this study, we focused on the RFEs in which patients request for a diagnostic or therapeutic intervention. In our thorough literature review, no information was found on the request for interventions as RFE. We aim to analyse whether the frequency with which patients consult a GP to request an intervention has historically changed over the last three decades. Therefore, we investigated the changes in number of requests, the percentage of GP’s compliance with a request and the percentage of interventions originating from a request. Furthermore, we analysed the influence of these requests on the subsequent diagnostic process: does the final diagnosis differ between patients who present with a symptom/complaint combined with a request and patients who present with the same symptom/complaint without a request? Methods Design and data source We performed a retrospective cohort study, using data from the Family Medicine Network (FaMe-net), a primary health care registration network in The Netherlands (8,9). FaMe-net is a fusion between two important historical registration networks, the Continuous Morbidity Registration (10) and the Transition Project (11,12). Within this network, all encounters between GPs and patients are registered since 1971. In total, 21 general practices and 68 GPs participated in this network over the last 30 years (11,12). In the first decade, 17 practices and 37 GPs participated from which 29 GPs participated for 1 year and 7 for more than 8 years. In the last 20 years, 6 practices and 11 GPs participated from which 9 GPs for 20 years. Participating practices register RFE, diagnosis and interventions for all patient encounters according to the International Classification of Primary Care [ICPC (13–15)]. Clear agreements have been made for coding RFE, diagnosis and interventions. Participating GPs have regular meetings to maintain quality of registering, discuss coding problems and receive feedback on their coding. Moreover, monthly, they fill in a questionnaire with immediate feedback about how to code several cases. Overall, participating GPs have special interest in primary care research. They register the RFE as close to the patients’ own words as possible. Interpretation of the GP is not allowed in the RFE. For example, when a patient comes in for tiredness and the GP may deem a blood test is necessary, this blood test is not coded as RFE. However, when the patient presents with ‘I am so tired, can I get a blood test?’, then both tiredness and request for a blood test are coded as RFE. Patient encounters are categorized into episodes of care. An episode of care is defined as ‘a health problem in an individual from the first presentation until the completion of the last encounter’. For example, a patient presenting with tiredness is diagnosed and treated for anaemia after a blood test. An episode of care encloses all contacts related to the health problem (in this case anaemia) and the title of the episode of care (diagnostic label) may be modified over time [in this case from tiredness to anaemia (2,16)]. Population and procedure We included all patients who visited their general practice with a request for an intervention as RFE between 1 January 1985 and 31 December 2014. We excluded telephone consultations (as these were not registered in 1985–1995), repeat prescriptions and administrative contacts. We only investigated the first encounter of an episode of care, because the RFE in follow-up encounters might be influenced by the GP. For example, when the GP suggests in the first encounter to refer to another care provider when it is not getting better after several weeks, the patient might ask for this referral in the next encounter. We divided the study period into three periods of 10 years: 1985–1994 (period 1), 1995–2004 (period 2) and 2005–2014 (period 3). The ICPC includes 18 codes for requests for intervention, of which we included seven based on relevance and frequency (Fig. 1). The excluded codes are almost never requested for by patients as RFE in the first consultation of an episode of care. Intervention codes *33 and *34 were analysed together, because almost all *33 are immunological blood tests. For each time period, we analysed the total number (n) and the number per 1000 patient years of requests as RFE and the actual intervention(s) performed by the GP in the same encounter. We defined that the GP was compliant with the request if the actual intervention was similar to the RFE in the same encounter. To investigate whether GPs’ interventions resulted from patients’ prior explicit request, we analysed the interventions performed by the GP and whether this was preceded by patient’s request for this intervention. Figure 1. View largeDownload slide Included requests for interventions during primary care encounters from 1985 to 2014 Figure 1. View largeDownload slide Included requests for interventions during primary care encounters from 1985 to 2014 To investigate the difference in diagnoses between patients who present with a request as RFE combined with a symptom/complaint and patients with the same symptom/complaint but without a request, we used data from the last 20 years. We excluded the first 10 years, because in that period many GPs only registered for 1 year. In the last 20 years, most of the GPs registered for more than 15 years and as a result, the outcome is less affected by changes of the GPs. We selected all encounters in which patients requested an intervention as RFE and analysed which other RFEs were coded in the same encounter (e.g. a request for a urine test combined with the symptom painful urination as other RFE). Subsequently, we selected all these other RFEs with a cut-off value of n = 50 over the last 20 years. Patients with a combination of a request for intervention and another RFE were compared with patients presenting with this other RFE without a request. We compared the final diagnosis in both groups, making a distinction between a symptom diagnosis (ICPC 1–23 or 29) and a disease diagnosis (ICPC 70–99). Symptom diagnoses are given when the relevant diagnostic criteria for a disease are not met (17,18). Statistical analysis We compared the number of RFEs and interventions between the three time periods by calculating rates (number per 1000 patient years) and rate ratios comparing periods 1 and 2 with period 3. Confidence intervals were determined by using Taylor series. We performed crosstab analyses to compare GPs’ compliance with patients’ requests between time periods, to compare the number of interventions with a preceding patients’ request between time periods and to determine differences in diagnosis between patients with or without a request. Chi-square tests and odds ratios were calculated. Data were analysed using OpenEpi version 3.01 and IBM SPSS Statistics version 22.0. Results Patient characteristics Table 1 shows included patients’ characteristics for each time period. Patient years are presented to compare these periods. Period 2 contains the most patient years, while period 3 contains the highest number of encounters. Age and gender distribution is equal over the time periods. Table 1. Patient characteristics during primary care encounters from 1985 to 2014 Period 1: 1985–94 Period 2: 1995–2004 Period 3: 2005–14 Number of patients 99332 151296 143787 Gender Male 46981 (47.3%) 73415 (48.5%) 69926 (48.6%) Female 52351 (52.7%) 77881(51.5%) 73861 (51.4%) Age 0–4 6071 (6.1%) 9672 (6.4%) 8516 (5.9%) 5–14 9769 (9.8%) 19192 (12.7%) 17509 (12.2%) 15–24 13103 (13.2%) 16412 (10.8%) 16149 (11.2%) 25–44 32522 (32.7%) 47459 (31.4%) 37362 (26%) 45–64 18455 (18.6%) 35647 (23.6%) 40542 (28.2%) 65–74 10925 (11%) 11538 (7.6%) 11697 (8.1%) 75+ 8487 (8.5%) 11376 (7.5%) 12012 (8.4%) Patient years 88306 142159 135548 Number of encounters Total 266309 393742 436739 Number per patient yeara (95% CI) 3.004 (3.016–3.027) 2.761 (2.77–2.778) 3.22 (3.229–3.239) Period 1: 1985–94 Period 2: 1995–2004 Period 3: 2005–14 Number of patients 99332 151296 143787 Gender Male 46981 (47.3%) 73415 (48.5%) 69926 (48.6%) Female 52351 (52.7%) 77881(51.5%) 73861 (51.4%) Age 0–4 6071 (6.1%) 9672 (6.4%) 8516 (5.9%) 5–14 9769 (9.8%) 19192 (12.7%) 17509 (12.2%) 15–24 13103 (13.2%) 16412 (10.8%) 16149 (11.2%) 25–44 32522 (32.7%) 47459 (31.4%) 37362 (26%) 45–64 18455 (18.6%) 35647 (23.6%) 40542 (28.2%) 65–74 10925 (11%) 11538 (7.6%) 11697 (8.1%) 75+ 8487 (8.5%) 11376 (7.5%) 12012 (8.4%) Patient years 88306 142159 135548 Number of encounters Total 266309 393742 436739 Number per patient yeara (95% CI) 3.004 (3.016–3.027) 2.761 (2.77–2.778) 3.22 (3.229–3.239) CI, confidence interval. aA patient year is a corrected year: if a patient is subscribed 10 years to the practice, then this patient contributes 10 patient years, and if a patient is subscribed for only 1 month, then this patient contributes 1/12 patient years to the total amount of patient years. View Large Table 1. Patient characteristics during primary care encounters from 1985 to 2014 Period 1: 1985–94 Period 2: 1995–2004 Period 3: 2005–14 Number of patients 99332 151296 143787 Gender Male 46981 (47.3%) 73415 (48.5%) 69926 (48.6%) Female 52351 (52.7%) 77881(51.5%) 73861 (51.4%) Age 0–4 6071 (6.1%) 9672 (6.4%) 8516 (5.9%) 5–14 9769 (9.8%) 19192 (12.7%) 17509 (12.2%) 15–24 13103 (13.2%) 16412 (10.8%) 16149 (11.2%) 25–44 32522 (32.7%) 47459 (31.4%) 37362 (26%) 45–64 18455 (18.6%) 35647 (23.6%) 40542 (28.2%) 65–74 10925 (11%) 11538 (7.6%) 11697 (8.1%) 75+ 8487 (8.5%) 11376 (7.5%) 12012 (8.4%) Patient years 88306 142159 135548 Number of encounters Total 266309 393742 436739 Number per patient yeara (95% CI) 3.004 (3.016–3.027) 2.761 (2.77–2.778) 3.22 (3.229–3.239) Period 1: 1985–94 Period 2: 1995–2004 Period 3: 2005–14 Number of patients 99332 151296 143787 Gender Male 46981 (47.3%) 73415 (48.5%) 69926 (48.6%) Female 52351 (52.7%) 77881(51.5%) 73861 (51.4%) Age 0–4 6071 (6.1%) 9672 (6.4%) 8516 (5.9%) 5–14 9769 (9.8%) 19192 (12.7%) 17509 (12.2%) 15–24 13103 (13.2%) 16412 (10.8%) 16149 (11.2%) 25–44 32522 (32.7%) 47459 (31.4%) 37362 (26%) 45–64 18455 (18.6%) 35647 (23.6%) 40542 (28.2%) 65–74 10925 (11%) 11538 (7.6%) 11697 (8.1%) 75+ 8487 (8.5%) 11376 (7.5%) 12012 (8.4%) Patient years 88306 142159 135548 Number of encounters Total 266309 393742 436739 Number per patient yeara (95% CI) 3.004 (3.016–3.027) 2.761 (2.77–2.778) 3.22 (3.229–3.239) CI, confidence interval. aA patient year is a corrected year: if a patient is subscribed 10 years to the practice, then this patient contributes 10 patient years, and if a patient is subscribed for only 1 month, then this patient contributes 1/12 patient years to the total amount of patient years. View Large Requests for interventions over time Table 2 shows the trend in number of patients with a request for intervention as RFE and GPs’ compliance with these requests over the past 30 years. We found a significant increase for most requests over time (P < 0.001). For example, patients’ request for blood test increased from 11.4 to 23 per 1000 patient years [rate ratio = 2.02; confidence interval (CI) = 1.89–2.17; Supplementary Tables S1 and S2]. We found only one decrease in requests over time: patients’ request for referral to another primary care provider (rate ratio = 0.71; CI = 0.66–0.76; Supplementary Tables S1 and S2) decreased in the past 20 years. Table 2. Patients’ requests for interventions, GPs’ compliance with these interventions, and number of interventions preceded by patients’ request during primary care encounters from 1985 to 2014 Intervention Time perioda Presented as RFE per 1000 patient years (n) GPs’ compliance % Total number of intervention per 1000 patient years (n) Originally resulting from a request % Blood test 1 11.4* (1008) 90.3* 120.3* (10626) 8.6* 2 23.3 (3312) 91.7* 136.1* (19345) 15.7* 3 23 (3132) 94.1 225.9 (30616) 9.6 Urine test 1 1.8* (161) 88.2* 53.7* (4743) 3.0* 2 18.3* (2602) 94.1* 61.1* (8692) 28.2* 3 48.4 (6555) 100.0 109.7 (14871) 45.0 Radiology/imaging 1 1.8* (162) 70.4* 52.6* (4646) 2.5* 2 3.7* (519) 76.1* 61* (8669) 4.6 3 4.3 (577) 84.4 90.3 (12235) 4.0 Medication prescription 1 48.1* (4246) 91.0* 819.6* (72372) 5.3* 2 57.6 (8188) 93.7 669.4* (95158) 8.1* 3 58.9 (7979) 93.4 631.4 (85580) 8.7 Referral to other primary care provider 1 5.7* (506) 79.2* 65.8* (5812) 6.9* 2 14.6* (2078) 89.2 85.2* (12119) 15.3* 3 10.3 (1402) 89.4 79.4 (10759) 11.6 Referral to secondary care 1 10.1* (895) 68.8* 97.8* (8640) 7.1* 2 11.9* (1690) 81.1* 93.5* (13296) 10.3 3 16.2 (2192) 88.5 137.7 (18663) 10.4 Intervention Time perioda Presented as RFE per 1000 patient years (n) GPs’ compliance % Total number of intervention per 1000 patient years (n) Originally resulting from a request % Blood test 1 11.4* (1008) 90.3* 120.3* (10626) 8.6* 2 23.3 (3312) 91.7* 136.1* (19345) 15.7* 3 23 (3132) 94.1 225.9 (30616) 9.6 Urine test 1 1.8* (161) 88.2* 53.7* (4743) 3.0* 2 18.3* (2602) 94.1* 61.1* (8692) 28.2* 3 48.4 (6555) 100.0 109.7 (14871) 45.0 Radiology/imaging 1 1.8* (162) 70.4* 52.6* (4646) 2.5* 2 3.7* (519) 76.1* 61* (8669) 4.6 3 4.3 (577) 84.4 90.3 (12235) 4.0 Medication prescription 1 48.1* (4246) 91.0* 819.6* (72372) 5.3* 2 57.6 (8188) 93.7 669.4* (95158) 8.1* 3 58.9 (7979) 93.4 631.4 (85580) 8.7 Referral to other primary care provider 1 5.7* (506) 79.2* 65.8* (5812) 6.9* 2 14.6* (2078) 89.2 85.2* (12119) 15.3* 3 10.3 (1402) 89.4 79.4 (10759) 11.6 Referral to secondary care 1 10.1* (895) 68.8* 97.8* (8640) 7.1* 2 11.9* (1690) 81.1* 93.5* (13296) 10.3 3 16.2 (2192) 88.5 137.7 (18663) 10.4 RFE, reason for encounter. aPeriod 1: 1985–1994; period 2: 1995–2004; period 3: 2005–2014. *Significant difference (P < 0.05) compared with period 3, according to chi-square tests. View Large Table 2. Patients’ requests for interventions, GPs’ compliance with these interventions, and number of interventions preceded by patients’ request during primary care encounters from 1985 to 2014 Intervention Time perioda Presented as RFE per 1000 patient years (n) GPs’ compliance % Total number of intervention per 1000 patient years (n) Originally resulting from a request % Blood test 1 11.4* (1008) 90.3* 120.3* (10626) 8.6* 2 23.3 (3312) 91.7* 136.1* (19345) 15.7* 3 23 (3132) 94.1 225.9 (30616) 9.6 Urine test 1 1.8* (161) 88.2* 53.7* (4743) 3.0* 2 18.3* (2602) 94.1* 61.1* (8692) 28.2* 3 48.4 (6555) 100.0 109.7 (14871) 45.0 Radiology/imaging 1 1.8* (162) 70.4* 52.6* (4646) 2.5* 2 3.7* (519) 76.1* 61* (8669) 4.6 3 4.3 (577) 84.4 90.3 (12235) 4.0 Medication prescription 1 48.1* (4246) 91.0* 819.6* (72372) 5.3* 2 57.6 (8188) 93.7 669.4* (95158) 8.1* 3 58.9 (7979) 93.4 631.4 (85580) 8.7 Referral to other primary care provider 1 5.7* (506) 79.2* 65.8* (5812) 6.9* 2 14.6* (2078) 89.2 85.2* (12119) 15.3* 3 10.3 (1402) 89.4 79.4 (10759) 11.6 Referral to secondary care 1 10.1* (895) 68.8* 97.8* (8640) 7.1* 2 11.9* (1690) 81.1* 93.5* (13296) 10.3 3 16.2 (2192) 88.5 137.7 (18663) 10.4 Intervention Time perioda Presented as RFE per 1000 patient years (n) GPs’ compliance % Total number of intervention per 1000 patient years (n) Originally resulting from a request % Blood test 1 11.4* (1008) 90.3* 120.3* (10626) 8.6* 2 23.3 (3312) 91.7* 136.1* (19345) 15.7* 3 23 (3132) 94.1 225.9 (30616) 9.6 Urine test 1 1.8* (161) 88.2* 53.7* (4743) 3.0* 2 18.3* (2602) 94.1* 61.1* (8692) 28.2* 3 48.4 (6555) 100.0 109.7 (14871) 45.0 Radiology/imaging 1 1.8* (162) 70.4* 52.6* (4646) 2.5* 2 3.7* (519) 76.1* 61* (8669) 4.6 3 4.3 (577) 84.4 90.3 (12235) 4.0 Medication prescription 1 48.1* (4246) 91.0* 819.6* (72372) 5.3* 2 57.6 (8188) 93.7 669.4* (95158) 8.1* 3 58.9 (7979) 93.4 631.4 (85580) 8.7 Referral to other primary care provider 1 5.7* (506) 79.2* 65.8* (5812) 6.9* 2 14.6* (2078) 89.2 85.2* (12119) 15.3* 3 10.3 (1402) 89.4 79.4 (10759) 11.6 Referral to secondary care 1 10.1* (895) 68.8* 97.8* (8640) 7.1* 2 11.9* (1690) 81.1* 93.5* (13296) 10.3 3 16.2 (2192) 88.5 137.7 (18663) 10.4 RFE, reason for encounter. aPeriod 1: 1985–1994; period 2: 1995–2004; period 3: 2005–2014. *Significant difference (P < 0.05) compared with period 3, according to chi-square tests. View Large GPs are compliant with most requests (range: 68.8%–93.7%; Table 2). This compliance increases significantly over time for all requests. Table 2 also shows the total number of each intervention over time. Over the past 30 years, we found an increase in total blood tests, urine tests, radiology and referrals to primary and secondary care and a decrease in medication prescription. The percentages of interventions preceding by patients’ requests significantly increase when comparing periods 1 and 3, while we see smaller increases or even decreases when comparing periods 2 and 3. Difference in final diagnosis in patients with a request Table 3 shows the difference in final symptom diagnoses between patients presenting with a symptom/complaint combined with a request and patients presenting with the same symptom/complaint without a request. For example, the combination of a request for a blood test and vertigo/dizziness as RFE occurred in 187 cases and resulted in a final symptom diagnosis in 79.1%. Patients presenting with vertigo/dizziness without a request for a blood test were diagnosed with a final symptom diagnosis in 54.5%. Overall, when patients requested an intervention for blood test, radiology, medication prescription and referral to primary or secondary care in addition to a symptom/complaint, a higher likelihood of a final symptom diagnosis was found compared with patients presenting with the same symptom/complaint without a request. In contrary, for patients requesting a urine test in addition to a symptom/complaint, a lower likelihood of a final symptom diagnosis was found compared with patients presenting with the same symptom/complaint without this request. Most of these patients were diagnosed with the disease diagnosis cystitis. Table 3. Final symptom diagnoses between patients with and without a request during primary care encounters from 1985 to 2014 First RFE Second RFE Prevalence of second RFE per 1000 patient years (n) Percentage of final symptom diagnoses in patients with a request (n) Percentage of final symptom diagnoses in patients without a request (n) ORa CIb (95%) P value Blood test Headache 0.2 (56) 91.1 (51) 60.7 (5131) 6.61 2.64–16.58 <0.001* Vertigo/dizziness 0.7 (187) 79.1 (148) 54.5 (3377) 3.17 2.22–4.53 <0.001* Weakness/tiredness, general 3.4 (951) 87.6 (833) 70.2 (7591) 2.99 2.46–3.64 <0.001* Fear of AIDS 0.2 (59) 5.1 (3) 2.5 (2) 2.11 0.34–13.08 0.410 Excessive thirst 0.3 (72) 76.4 (55) 67.7 (285) 1.54 0.86–2.76 0.141 Prevention 0.3 (85) 3.5 (3) 3 (48) 1.19 0.36–3.91 0.772 Risk factor cardiovascular disease 0.2 (67) 80.6 (54) 87 (321) 0.62 0.32–1.22 0.165 Fear of an endocrine/metabolic disease 0.4 (114) 1.1 (16) 14.8 (56) 0.06 0.04–0.11 <0.001* Urine test Fever 0.4 (107) 31.8 (34) 15.1 (1966) 2.61 1.73–3.93 <0.001* Cystitis 1.8 (505) 8.3 (42) 4.7 (101) 1.86 1.28–2.70 0.001* Abdominal pain, generalized 0.3 (82) 68.3 (56) 56.7 (1972) 1.65 1.03–2.64 0.035* Painful urination 9.1 (2538) 31.6 (802) 24.8 (801) 1.40 1.25–1.57 <0.001* Urine complaints, other 0.7 (193) 59.6 (115) 64.1 (141) 0.83 0.56–1.23 0.347 Flank complaints 0.4 (116) 58.6 (68) 64.4 (1071) 0.78 0.53–1.15 0.210 Frequent/urgent urination 7.4 (2067) 35.4 (731) 41.9 (1470) 0.76 0.68–0.85 <0.001* Abdominal pain, localized 2.8 (783) 54.7 (428) 63.9 (6606) 0.68 0.56–0.79 <0.001* Blood in urine 0.7 (195) 36.4 (71) 52.8 (374) 0.51 0.37–0.71 <0.001* Incontinence 0.3 (76) 63.2 (48) 79 (793) 0.46 0.28–0.75 <0.001* Low back complaints 0.5 (140) 63.6 (89) 80.8 (7927) 0.41 0.29–0.59 <0.001* Fear of a urinary disease 0.6 (168) 4.2 (7) 12.4 (93) 0.31 0.14–0.68 0.002* Back complaints 0.2 (58) 55.2 (32) 81.1 (3058) 0.29 0.17–0.49 <0.001* Radiology/imaging Knee complaints 0.2 (65) 63.1 (41) 50.7 (4070) 1.66 1.00–2.75 0.047* Low back complaints 0.3 (74) 83.8 (62) 80.6 (8016) 1.25 0.67–2.32 0.485 Medication prescription Constipation 0.4 (102) 99 (1) 90.5 (1915) 10.6 1.47–76.40 0.003* Disturbances of sleep/insomnia 1.4 (383) 96.1 (368) 88.1 (2097) 3.23 1.95–5.65 <0.001* Feeling anxious/nervous/tense 0.7 (206) 89.8 (185) 76.7 (2418) 2.67 1.69–4.23 <0.001* Low back complaints 0.6 (154) 91.6 (141) 80.4 (7875) 2.64 1.49–4.67 0.001* Cough 2.2 (606) 43.6 (264) 28.2 (8128) 1.97 1.67–2.31 <0.001* Headache 0.4 (115) 71.3 (82) 60.7 (5100) 1.61 1.07–2.41 0.021* Pruritis 0.3 (90) 36.7 (22) 28.7 (2117) 1.44 0.94–2.21 0.097 Local redness/erythema/rash 0.4 (107) 14 (15) 13.8 (2116) 1.0 0.59–1.77 0.940 Acute upper respiratory infection 0.6 (159) 6.9 (11) 7.9 (526) 0.87 0.47–1.60 0.647 Shortness of breath/dyspnoea 0.3 (89) 22.5 (20) 29 (2456) 0.71 0.43–1.17 0.177 Throat complaints 0.5 (152) 25.7 (39) 34.3 (4188) 0.66 0.46–0.95 0.026* Acute/chronic sinusitis 0.5 (129) 2.3 (3) 4.6 (62) 0.50 0.15–1.61 0.235 Prevention 0.5 (133) 1.5 (2) 3.1 (49) 0.47 0.11–1.96 0.427c Oral contraceptive 0.7 (196) 2 (4) 4.8 (48) 0.42 0.15–1.12 0.086 Dermatophytosis 0.5 (141) 0.7 (1) 1.9 (44) 0.38 0.05–2.76 0.319 Cystitis 0.6 (159) 1.3 (2) 5.6 (141) 0.22 0.053–0.88 0.018* Painful urination 0.4 (100) 5 (5) 28.2 (1598) 0.13 0.054–0.33 <0.001* Referral to other primary care provider Neck complaints 1.4 (402) 96.8 (389) 84.3 (4911) 5.57 3.19–9.72 <0.001* Shoulder complaints 0.6 (180) 85 (153) 50.6 (3843) 5.54 3.67–8.35 <0.001* Back complaints 0.4 (110) 95.5 (105) 80.2 (2985) 5.17 2.10–12.73 <0.001* Low back complaints 1.2 (330) 94.5 (312) 80.1 (7704) 4.30 2.67–6.94 <0.001* Foot/toe complaints 0.2 (62) 75.8 (47) 47.2 (4164) 3.50 1.96–6.27 <0.001* Arm complaints 0.2 (51) 78.4 (40) 52.3 (2074) 3.32 1.67–6.49 <0.001* Feeling depressed 0.2 (52) 78.8 (41) 58.8 (1196) 2.61 1.33–5.10 0.004* Knee complaints 0.2 (55) 72.7 (40) 50.7 (4071) 2.60 1.43–4.71 0.001* Leg/thigh complaints 0.2 (54) 70.4 (38) 53.4 (3869) 2.07 1.15–3.73 0.013* Feeling anxious/nervous/tense 0.2 (55) 87.3 (48) 77.4 (2555) 2.00 0.90–4.45 0.081 Relation problem partners 0.3 (81) 97.5 (79) 97.2 (840) 1.13 0.26–4.86 0.871 Overweight (BMI < 30) 0.2 (56) 0 (0) 2.7 (15) 1.10 1.08–1.13 0.212 Referral to secondary care Hearing complaints 0.2 (69) 46.4 (64) 13.9 (2026) 5.34 3.81–7.49 <0.001* Local swelling/papule/lump/mass 0.4 (99) 43.4 (86) 28 (7588) 1.98 1.49–2.63 <0.001* Visual complaints, other 0.4 (105) 66.7 (70) 54.8 (1018) 1.65 1.09–2.50 0.017* Nevus/mole 0.3 (71) 0 (0) 1.4 (72) 1.03 1.02–1.03 0.153 First RFE Second RFE Prevalence of second RFE per 1000 patient years (n) Percentage of final symptom diagnoses in patients with a request (n) Percentage of final symptom diagnoses in patients without a request (n) ORa CIb (95%) P value Blood test Headache 0.2 (56) 91.1 (51) 60.7 (5131) 6.61 2.64–16.58 <0.001* Vertigo/dizziness 0.7 (187) 79.1 (148) 54.5 (3377) 3.17 2.22–4.53 <0.001* Weakness/tiredness, general 3.4 (951) 87.6 (833) 70.2 (7591) 2.99 2.46–3.64 <0.001* Fear of AIDS 0.2 (59) 5.1 (3) 2.5 (2) 2.11 0.34–13.08 0.410 Excessive thirst 0.3 (72) 76.4 (55) 67.7 (285) 1.54 0.86–2.76 0.141 Prevention 0.3 (85) 3.5 (3) 3 (48) 1.19 0.36–3.91 0.772 Risk factor cardiovascular disease 0.2 (67) 80.6 (54) 87 (321) 0.62 0.32–1.22 0.165 Fear of an endocrine/metabolic disease 0.4 (114) 1.1 (16) 14.8 (56) 0.06 0.04–0.11 <0.001* Urine test Fever 0.4 (107) 31.8 (34) 15.1 (1966) 2.61 1.73–3.93 <0.001* Cystitis 1.8 (505) 8.3 (42) 4.7 (101) 1.86 1.28–2.70 0.001* Abdominal pain, generalized 0.3 (82) 68.3 (56) 56.7 (1972) 1.65 1.03–2.64 0.035* Painful urination 9.1 (2538) 31.6 (802) 24.8 (801) 1.40 1.25–1.57 <0.001* Urine complaints, other 0.7 (193) 59.6 (115) 64.1 (141) 0.83 0.56–1.23 0.347 Flank complaints 0.4 (116) 58.6 (68) 64.4 (1071) 0.78 0.53–1.15 0.210 Frequent/urgent urination 7.4 (2067) 35.4 (731) 41.9 (1470) 0.76 0.68–0.85 <0.001* Abdominal pain, localized 2.8 (783) 54.7 (428) 63.9 (6606) 0.68 0.56–0.79 <0.001* Blood in urine 0.7 (195) 36.4 (71) 52.8 (374) 0.51 0.37–0.71 <0.001* Incontinence 0.3 (76) 63.2 (48) 79 (793) 0.46 0.28–0.75 <0.001* Low back complaints 0.5 (140) 63.6 (89) 80.8 (7927) 0.41 0.29–0.59 <0.001* Fear of a urinary disease 0.6 (168) 4.2 (7) 12.4 (93) 0.31 0.14–0.68 0.002* Back complaints 0.2 (58) 55.2 (32) 81.1 (3058) 0.29 0.17–0.49 <0.001* Radiology/imaging Knee complaints 0.2 (65) 63.1 (41) 50.7 (4070) 1.66 1.00–2.75 0.047* Low back complaints 0.3 (74) 83.8 (62) 80.6 (8016) 1.25 0.67–2.32 0.485 Medication prescription Constipation 0.4 (102) 99 (1) 90.5 (1915) 10.6 1.47–76.40 0.003* Disturbances of sleep/insomnia 1.4 (383) 96.1 (368) 88.1 (2097) 3.23 1.95–5.65 <0.001* Feeling anxious/nervous/tense 0.7 (206) 89.8 (185) 76.7 (2418) 2.67 1.69–4.23 <0.001* Low back complaints 0.6 (154) 91.6 (141) 80.4 (7875) 2.64 1.49–4.67 0.001* Cough 2.2 (606) 43.6 (264) 28.2 (8128) 1.97 1.67–2.31 <0.001* Headache 0.4 (115) 71.3 (82) 60.7 (5100) 1.61 1.07–2.41 0.021* Pruritis 0.3 (90) 36.7 (22) 28.7 (2117) 1.44 0.94–2.21 0.097 Local redness/erythema/rash 0.4 (107) 14 (15) 13.8 (2116) 1.0 0.59–1.77 0.940 Acute upper respiratory infection 0.6 (159) 6.9 (11) 7.9 (526) 0.87 0.47–1.60 0.647 Shortness of breath/dyspnoea 0.3 (89) 22.5 (20) 29 (2456) 0.71 0.43–1.17 0.177 Throat complaints 0.5 (152) 25.7 (39) 34.3 (4188) 0.66 0.46–0.95 0.026* Acute/chronic sinusitis 0.5 (129) 2.3 (3) 4.6 (62) 0.50 0.15–1.61 0.235 Prevention 0.5 (133) 1.5 (2) 3.1 (49) 0.47 0.11–1.96 0.427c Oral contraceptive 0.7 (196) 2 (4) 4.8 (48) 0.42 0.15–1.12 0.086 Dermatophytosis 0.5 (141) 0.7 (1) 1.9 (44) 0.38 0.05–2.76 0.319 Cystitis 0.6 (159) 1.3 (2) 5.6 (141) 0.22 0.053–0.88 0.018* Painful urination 0.4 (100) 5 (5) 28.2 (1598) 0.13 0.054–0.33 <0.001* Referral to other primary care provider Neck complaints 1.4 (402) 96.8 (389) 84.3 (4911) 5.57 3.19–9.72 <0.001* Shoulder complaints 0.6 (180) 85 (153) 50.6 (3843) 5.54 3.67–8.35 <0.001* Back complaints 0.4 (110) 95.5 (105) 80.2 (2985) 5.17 2.10–12.73 <0.001* Low back complaints 1.2 (330) 94.5 (312) 80.1 (7704) 4.30 2.67–6.94 <0.001* Foot/toe complaints 0.2 (62) 75.8 (47) 47.2 (4164) 3.50 1.96–6.27 <0.001* Arm complaints 0.2 (51) 78.4 (40) 52.3 (2074) 3.32 1.67–6.49 <0.001* Feeling depressed 0.2 (52) 78.8 (41) 58.8 (1196) 2.61 1.33–5.10 0.004* Knee complaints 0.2 (55) 72.7 (40) 50.7 (4071) 2.60 1.43–4.71 0.001* Leg/thigh complaints 0.2 (54) 70.4 (38) 53.4 (3869) 2.07 1.15–3.73 0.013* Feeling anxious/nervous/tense 0.2 (55) 87.3 (48) 77.4 (2555) 2.00 0.90–4.45 0.081 Relation problem partners 0.3 (81) 97.5 (79) 97.2 (840) 1.13 0.26–4.86 0.871 Overweight (BMI < 30) 0.2 (56) 0 (0) 2.7 (15) 1.10 1.08–1.13 0.212 Referral to secondary care Hearing complaints 0.2 (69) 46.4 (64) 13.9 (2026) 5.34 3.81–7.49 <0.001* Local swelling/papule/lump/mass 0.4 (99) 43.4 (86) 28 (7588) 1.98 1.49–2.63 <0.001* Visual complaints, other 0.4 (105) 66.7 (70) 54.8 (1018) 1.65 1.09–2.50 0.017* Nevus/mole 0.3 (71) 0 (0) 1.4 (72) 1.03 1.02–1.03 0.153 AIDS, acquired immune deficiency syndrome; BMI, body mass index; RFE, reason for encounter aOdds ratio, the odds of having a symptom diagnoses if presenting with a symptom and a request compared to the odds of having a symptom diagnosis without a request for intervention. bConfidence interval, determined by using Taylor series. cExpected count less than 5, Fisher’s exact test was used. *P value below 0.05, according to chi-square tests. View Large Table 3. Final symptom diagnoses between patients with and without a request during primary care encounters from 1985 to 2014 First RFE Second RFE Prevalence of second RFE per 1000 patient years (n) Percentage of final symptom diagnoses in patients with a request (n) Percentage of final symptom diagnoses in patients without a request (n) ORa CIb (95%) P value Blood test Headache 0.2 (56) 91.1 (51) 60.7 (5131) 6.61 2.64–16.58 <0.001* Vertigo/dizziness 0.7 (187) 79.1 (148) 54.5 (3377) 3.17 2.22–4.53 <0.001* Weakness/tiredness, general 3.4 (951) 87.6 (833) 70.2 (7591) 2.99 2.46–3.64 <0.001* Fear of AIDS 0.2 (59) 5.1 (3) 2.5 (2) 2.11 0.34–13.08 0.410 Excessive thirst 0.3 (72) 76.4 (55) 67.7 (285) 1.54 0.86–2.76 0.141 Prevention 0.3 (85) 3.5 (3) 3 (48) 1.19 0.36–3.91 0.772 Risk factor cardiovascular disease 0.2 (67) 80.6 (54) 87 (321) 0.62 0.32–1.22 0.165 Fear of an endocrine/metabolic disease 0.4 (114) 1.1 (16) 14.8 (56) 0.06 0.04–0.11 <0.001* Urine test Fever 0.4 (107) 31.8 (34) 15.1 (1966) 2.61 1.73–3.93 <0.001* Cystitis 1.8 (505) 8.3 (42) 4.7 (101) 1.86 1.28–2.70 0.001* Abdominal pain, generalized 0.3 (82) 68.3 (56) 56.7 (1972) 1.65 1.03–2.64 0.035* Painful urination 9.1 (2538) 31.6 (802) 24.8 (801) 1.40 1.25–1.57 <0.001* Urine complaints, other 0.7 (193) 59.6 (115) 64.1 (141) 0.83 0.56–1.23 0.347 Flank complaints 0.4 (116) 58.6 (68) 64.4 (1071) 0.78 0.53–1.15 0.210 Frequent/urgent urination 7.4 (2067) 35.4 (731) 41.9 (1470) 0.76 0.68–0.85 <0.001* Abdominal pain, localized 2.8 (783) 54.7 (428) 63.9 (6606) 0.68 0.56–0.79 <0.001* Blood in urine 0.7 (195) 36.4 (71) 52.8 (374) 0.51 0.37–0.71 <0.001* Incontinence 0.3 (76) 63.2 (48) 79 (793) 0.46 0.28–0.75 <0.001* Low back complaints 0.5 (140) 63.6 (89) 80.8 (7927) 0.41 0.29–0.59 <0.001* Fear of a urinary disease 0.6 (168) 4.2 (7) 12.4 (93) 0.31 0.14–0.68 0.002* Back complaints 0.2 (58) 55.2 (32) 81.1 (3058) 0.29 0.17–0.49 <0.001* Radiology/imaging Knee complaints 0.2 (65) 63.1 (41) 50.7 (4070) 1.66 1.00–2.75 0.047* Low back complaints 0.3 (74) 83.8 (62) 80.6 (8016) 1.25 0.67–2.32 0.485 Medication prescription Constipation 0.4 (102) 99 (1) 90.5 (1915) 10.6 1.47–76.40 0.003* Disturbances of sleep/insomnia 1.4 (383) 96.1 (368) 88.1 (2097) 3.23 1.95–5.65 <0.001* Feeling anxious/nervous/tense 0.7 (206) 89.8 (185) 76.7 (2418) 2.67 1.69–4.23 <0.001* Low back complaints 0.6 (154) 91.6 (141) 80.4 (7875) 2.64 1.49–4.67 0.001* Cough 2.2 (606) 43.6 (264) 28.2 (8128) 1.97 1.67–2.31 <0.001* Headache 0.4 (115) 71.3 (82) 60.7 (5100) 1.61 1.07–2.41 0.021* Pruritis 0.3 (90) 36.7 (22) 28.7 (2117) 1.44 0.94–2.21 0.097 Local redness/erythema/rash 0.4 (107) 14 (15) 13.8 (2116) 1.0 0.59–1.77 0.940 Acute upper respiratory infection 0.6 (159) 6.9 (11) 7.9 (526) 0.87 0.47–1.60 0.647 Shortness of breath/dyspnoea 0.3 (89) 22.5 (20) 29 (2456) 0.71 0.43–1.17 0.177 Throat complaints 0.5 (152) 25.7 (39) 34.3 (4188) 0.66 0.46–0.95 0.026* Acute/chronic sinusitis 0.5 (129) 2.3 (3) 4.6 (62) 0.50 0.15–1.61 0.235 Prevention 0.5 (133) 1.5 (2) 3.1 (49) 0.47 0.11–1.96 0.427c Oral contraceptive 0.7 (196) 2 (4) 4.8 (48) 0.42 0.15–1.12 0.086 Dermatophytosis 0.5 (141) 0.7 (1) 1.9 (44) 0.38 0.05–2.76 0.319 Cystitis 0.6 (159) 1.3 (2) 5.6 (141) 0.22 0.053–0.88 0.018* Painful urination 0.4 (100) 5 (5) 28.2 (1598) 0.13 0.054–0.33 <0.001* Referral to other primary care provider Neck complaints 1.4 (402) 96.8 (389) 84.3 (4911) 5.57 3.19–9.72 <0.001* Shoulder complaints 0.6 (180) 85 (153) 50.6 (3843) 5.54 3.67–8.35 <0.001* Back complaints 0.4 (110) 95.5 (105) 80.2 (2985) 5.17 2.10–12.73 <0.001* Low back complaints 1.2 (330) 94.5 (312) 80.1 (7704) 4.30 2.67–6.94 <0.001* Foot/toe complaints 0.2 (62) 75.8 (47) 47.2 (4164) 3.50 1.96–6.27 <0.001* Arm complaints 0.2 (51) 78.4 (40) 52.3 (2074) 3.32 1.67–6.49 <0.001* Feeling depressed 0.2 (52) 78.8 (41) 58.8 (1196) 2.61 1.33–5.10 0.004* Knee complaints 0.2 (55) 72.7 (40) 50.7 (4071) 2.60 1.43–4.71 0.001* Leg/thigh complaints 0.2 (54) 70.4 (38) 53.4 (3869) 2.07 1.15–3.73 0.013* Feeling anxious/nervous/tense 0.2 (55) 87.3 (48) 77.4 (2555) 2.00 0.90–4.45 0.081 Relation problem partners 0.3 (81) 97.5 (79) 97.2 (840) 1.13 0.26–4.86 0.871 Overweight (BMI < 30) 0.2 (56) 0 (0) 2.7 (15) 1.10 1.08–1.13 0.212 Referral to secondary care Hearing complaints 0.2 (69) 46.4 (64) 13.9 (2026) 5.34 3.81–7.49 <0.001* Local swelling/papule/lump/mass 0.4 (99) 43.4 (86) 28 (7588) 1.98 1.49–2.63 <0.001* Visual complaints, other 0.4 (105) 66.7 (70) 54.8 (1018) 1.65 1.09–2.50 0.017* Nevus/mole 0.3 (71) 0 (0) 1.4 (72) 1.03 1.02–1.03 0.153 First RFE Second RFE Prevalence of second RFE per 1000 patient years (n) Percentage of final symptom diagnoses in patients with a request (n) Percentage of final symptom diagnoses in patients without a request (n) ORa CIb (95%) P value Blood test Headache 0.2 (56) 91.1 (51) 60.7 (5131) 6.61 2.64–16.58 <0.001* Vertigo/dizziness 0.7 (187) 79.1 (148) 54.5 (3377) 3.17 2.22–4.53 <0.001* Weakness/tiredness, general 3.4 (951) 87.6 (833) 70.2 (7591) 2.99 2.46–3.64 <0.001* Fear of AIDS 0.2 (59) 5.1 (3) 2.5 (2) 2.11 0.34–13.08 0.410 Excessive thirst 0.3 (72) 76.4 (55) 67.7 (285) 1.54 0.86–2.76 0.141 Prevention 0.3 (85) 3.5 (3) 3 (48) 1.19 0.36–3.91 0.772 Risk factor cardiovascular disease 0.2 (67) 80.6 (54) 87 (321) 0.62 0.32–1.22 0.165 Fear of an endocrine/metabolic disease 0.4 (114) 1.1 (16) 14.8 (56) 0.06 0.04–0.11 <0.001* Urine test Fever 0.4 (107) 31.8 (34) 15.1 (1966) 2.61 1.73–3.93 <0.001* Cystitis 1.8 (505) 8.3 (42) 4.7 (101) 1.86 1.28–2.70 0.001* Abdominal pain, generalized 0.3 (82) 68.3 (56) 56.7 (1972) 1.65 1.03–2.64 0.035* Painful urination 9.1 (2538) 31.6 (802) 24.8 (801) 1.40 1.25–1.57 <0.001* Urine complaints, other 0.7 (193) 59.6 (115) 64.1 (141) 0.83 0.56–1.23 0.347 Flank complaints 0.4 (116) 58.6 (68) 64.4 (1071) 0.78 0.53–1.15 0.210 Frequent/urgent urination 7.4 (2067) 35.4 (731) 41.9 (1470) 0.76 0.68–0.85 <0.001* Abdominal pain, localized 2.8 (783) 54.7 (428) 63.9 (6606) 0.68 0.56–0.79 <0.001* Blood in urine 0.7 (195) 36.4 (71) 52.8 (374) 0.51 0.37–0.71 <0.001* Incontinence 0.3 (76) 63.2 (48) 79 (793) 0.46 0.28–0.75 <0.001* Low back complaints 0.5 (140) 63.6 (89) 80.8 (7927) 0.41 0.29–0.59 <0.001* Fear of a urinary disease 0.6 (168) 4.2 (7) 12.4 (93) 0.31 0.14–0.68 0.002* Back complaints 0.2 (58) 55.2 (32) 81.1 (3058) 0.29 0.17–0.49 <0.001* Radiology/imaging Knee complaints 0.2 (65) 63.1 (41) 50.7 (4070) 1.66 1.00–2.75 0.047* Low back complaints 0.3 (74) 83.8 (62) 80.6 (8016) 1.25 0.67–2.32 0.485 Medication prescription Constipation 0.4 (102) 99 (1) 90.5 (1915) 10.6 1.47–76.40 0.003* Disturbances of sleep/insomnia 1.4 (383) 96.1 (368) 88.1 (2097) 3.23 1.95–5.65 <0.001* Feeling anxious/nervous/tense 0.7 (206) 89.8 (185) 76.7 (2418) 2.67 1.69–4.23 <0.001* Low back complaints 0.6 (154) 91.6 (141) 80.4 (7875) 2.64 1.49–4.67 0.001* Cough 2.2 (606) 43.6 (264) 28.2 (8128) 1.97 1.67–2.31 <0.001* Headache 0.4 (115) 71.3 (82) 60.7 (5100) 1.61 1.07–2.41 0.021* Pruritis 0.3 (90) 36.7 (22) 28.7 (2117) 1.44 0.94–2.21 0.097 Local redness/erythema/rash 0.4 (107) 14 (15) 13.8 (2116) 1.0 0.59–1.77 0.940 Acute upper respiratory infection 0.6 (159) 6.9 (11) 7.9 (526) 0.87 0.47–1.60 0.647 Shortness of breath/dyspnoea 0.3 (89) 22.5 (20) 29 (2456) 0.71 0.43–1.17 0.177 Throat complaints 0.5 (152) 25.7 (39) 34.3 (4188) 0.66 0.46–0.95 0.026* Acute/chronic sinusitis 0.5 (129) 2.3 (3) 4.6 (62) 0.50 0.15–1.61 0.235 Prevention 0.5 (133) 1.5 (2) 3.1 (49) 0.47 0.11–1.96 0.427c Oral contraceptive 0.7 (196) 2 (4) 4.8 (48) 0.42 0.15–1.12 0.086 Dermatophytosis 0.5 (141) 0.7 (1) 1.9 (44) 0.38 0.05–2.76 0.319 Cystitis 0.6 (159) 1.3 (2) 5.6 (141) 0.22 0.053–0.88 0.018* Painful urination 0.4 (100) 5 (5) 28.2 (1598) 0.13 0.054–0.33 <0.001* Referral to other primary care provider Neck complaints 1.4 (402) 96.8 (389) 84.3 (4911) 5.57 3.19–9.72 <0.001* Shoulder complaints 0.6 (180) 85 (153) 50.6 (3843) 5.54 3.67–8.35 <0.001* Back complaints 0.4 (110) 95.5 (105) 80.2 (2985) 5.17 2.10–12.73 <0.001* Low back complaints 1.2 (330) 94.5 (312) 80.1 (7704) 4.30 2.67–6.94 <0.001* Foot/toe complaints 0.2 (62) 75.8 (47) 47.2 (4164) 3.50 1.96–6.27 <0.001* Arm complaints 0.2 (51) 78.4 (40) 52.3 (2074) 3.32 1.67–6.49 <0.001* Feeling depressed 0.2 (52) 78.8 (41) 58.8 (1196) 2.61 1.33–5.10 0.004* Knee complaints 0.2 (55) 72.7 (40) 50.7 (4071) 2.60 1.43–4.71 0.001* Leg/thigh complaints 0.2 (54) 70.4 (38) 53.4 (3869) 2.07 1.15–3.73 0.013* Feeling anxious/nervous/tense 0.2 (55) 87.3 (48) 77.4 (2555) 2.00 0.90–4.45 0.081 Relation problem partners 0.3 (81) 97.5 (79) 97.2 (840) 1.13 0.26–4.86 0.871 Overweight (BMI < 30) 0.2 (56) 0 (0) 2.7 (15) 1.10 1.08–1.13 0.212 Referral to secondary care Hearing complaints 0.2 (69) 46.4 (64) 13.9 (2026) 5.34 3.81–7.49 <0.001* Local swelling/papule/lump/mass 0.4 (99) 43.4 (86) 28 (7588) 1.98 1.49–2.63 <0.001* Visual complaints, other 0.4 (105) 66.7 (70) 54.8 (1018) 1.65 1.09–2.50 0.017* Nevus/mole 0.3 (71) 0 (0) 1.4 (72) 1.03 1.02–1.03 0.153 AIDS, acquired immune deficiency syndrome; BMI, body mass index; RFE, reason for encounter aOdds ratio, the odds of having a symptom diagnoses if presenting with a symptom and a request compared to the odds of having a symptom diagnosis without a request for intervention. bConfidence interval, determined by using Taylor series. cExpected count less than 5, Fisher’s exact test was used. *P value below 0.05, according to chi-square tests. View Large Discussion This is the first study analysing changes in patients’ requests for diagnostic and therapeutic interventions and changes in GPs’ compliance with these requests over the last three decades. It provides insight into patients’ behaviour and its contribution to the doctor–patient encounter. We found that almost all patients’ requests for interventions increased over the last 30 years. This suggests that patients are more self-empowered nowadays. Patients can search for medical information on the Internet and get informed by health programmes on television. The highest increase was found for urine test requests, which might be associated with dipstick testing that became commonplace in general practice. We found only one decrease in requests over time: patients’ request for referral to another primary care provider decreased in the last 20 years. Explanations for this might be that patients nowadays do not need a referral letter anymore to visit the physiotherapist and consequently patients can make an appointment with the physiotherapist without interference of the GP. Another explanation for this decrease could be the introduction of patient’s own risk in health insurance (the amount you have to pay yourself before the insurance company covers the medical costs) since 2008. This own risk is applicable to all primary and secondary care, except GP care. When patients have to pay for physiotherapist care, they probably wait longer to see whether complaints will disappear by themselves. GPs’ compliance with all investigated requests increased significantly over the past 30 years. Maybe patients nowadays more frequently ask for interventions that are medically indicated according to the GP, while previously they more frequently asked for interventions that are not indicated according to the GP. Another explanation might be the increased focus on shared decision making between patient and doctor nowadays. The total number of each intervention performed by GPs increased over time, except for medication prescription and referral to another primary care provider. Nowadays, more medication is available over the counter, so no prescription is needed. Furthermore, an increasing number of GP guideline might increase GPs’ watchful waiting, instead of directly prescribing medication. The increase in the total number of each intervention could hypothetically be explained by the aging population; however, this is not confirmed by our patient characteristics. Another explanation might be that doctors nowadays are possibly willing to take less risks and thereby perform more interventions. Another possible reason for this increase could be explained by following the guidelines for diabetes and cardiovascular risk factors where more interventions are needed in the first encounter. We found that patients asking for an intervention are more likely to be finally diagnosed with a symptom rather than a disease, while patients presenting with a symptom without asking for an intervention are more likely to be diagnosed with a disease. Possibly, patients asking for an intervention are more worried about their symptoms, have searched more extensively for information on the Internet or heard in their surroundings that others with certain symptoms got a specific intervention. This may lead to a request for intervention when they present to their GP. GPs are compliant with most of these requests. Given the fact that these patients are more likely to be finally diagnosed with a symptom (the GP could not finally diagnose a clear disease), it is expected that most medical investigations performed because of patients’ request will finally result in no abnormalities. In contrary, patients who present with a request for urine test are more often diagnosed with cystitis compared with the group without a request. This may be due to the fact that a lot of patients with cystitis recognize their symptoms from a previous cystitis and therefore ask directly for a urine test. Strengths and limitations A strength of this study is the large number of patients and encounters included. A recent study showed that the population in our database is representative for other countries (12). A limitation is that the data in the first 10 years of our study are registered by many GPs who only registered data for a short period of time. Data in these first 10 years are therefore less reliable. Another limitation is that we could not establish whether or not interventions were appropriate, beneficial or harmful. GPs did not register whether or not an intervention was medically indicated when the patient was asking for it. A last limitation is that we did not adjust for confounding factors (e.g. the introduction of patient’s own risk), which could have biased the results. Comparison with existing literature In our study, the percentage of GPs’ compliance with requests is higher (87%, range: 69%–100%) than what Soler and Okkes (17) found (56%, range: 45%–79%). The number of interventions originating from a request is slightly lower (11%, range: 3%–45%) compared with that of Soler and Okkes [15%, range: 6%–26% (17)]. A possible explanation for these differences might be that Soler and Okkes, perhaps, included other types of encounters. In our study, we included only first encounters of an episode of care. We excluded telephone consultations, repeat prescriptions and administrative records. Implications for research and practice This study shows the clinical relevance of the RFE in the doctor–patient encounter. Being aware of the RFE will lead to important information about patient’s needs, worries, expectations and even results of medical investigations. The GP should use this information to explore possible underlying concern, anxiety or ignorance and to explain whether or not to be compliant with patient’s request. To be aware of the predictive value of a request leading to a diagnosis could be useful to decide together with the patient to perform or not to perform a certain test: when a patient asks for an intervention, the GP can decide to discuss the results of this study (i.e. it is expected that most medical investigations performed because of patients’ request will finally result in no abnormality), especially when the GP thinks the request is not necessary. More research in this area is needed for supporting these findings to implicate in daily practice. For example, if the GP is compliant with a request, was it because it was medically needed or just to reassure the patient because it was requested? Is it possible to prevent inappropriate testing and waste of resources leading to better clinical practice? Supplementary Material Supplementary data are available at Family Practice online. Declaration Funding: none. Ethical approval: not necessary, as we used an anonymised database. Conflict of interest: none. Acknowledgement This study would not have been possible without the participation of the Transition Project doctors. References 1. olde Hartman TC , van Ravesteijn H , Lucassen P , et al. Why the ‘reason for encounter’ should be incorporated in the analysis of outcome of care . Br J Gen Pract 2011 ; 61 : e839 – 41 . Google Scholar PubMed 2. Hofmans-Okkes IM , Lamberts H . The International Classification of Primary Care (ICPC): new applications in research and computer-based patient records in family practice . Fam Pract 1996 ; 13 : 294 – 302 . Google Scholar CrossRef Search ADS PubMed 3. Kravitz RL , Epstein RM , Feldman MD , et al. Influence of patients’ requests for direct-to-consumer advertised antidepressants: a randomized controlled trial . JAMA 2005 ; 293 : 1995 – 2002 . Google Scholar CrossRef Search ADS PubMed 4. Hyde J , Calnan M , Prior L , et al. A qualitative study exploring how GPs decide to prescribe antidepressants . Br J Gen Pract 2005 ; 55 : 755 – 62 . Google Scholar PubMed 5. Cohen O , Kahan E , Zalewski S , Kitai E . Medical investigations requested by patients: how do primary care physicians react ? Fam Med 1999 ; 31 : 426 – 31 . Google Scholar PubMed 6. van Boven K , Uijen A , Wiel N , et al. Clinical relevance of alarm symptoms as reason for encounter for diagnosing cancer in primary care . J Am Board Fam Med November-December 2017; 30(6): 806–812 . 7. van Boxtel-Wilms SJ , van Boven K , Bor JH , et al. The value of reasons for encounter in early detection of colorectal cancer . Eur J Gen Pract 2016; 22 : 1 – 5 . 8. FaMe-net . www.transhis.nl. 9. Uijen A , Bor H , Boven K . FaMe-Net: twee oude registratienetwerken in een nieuw jasje . Tijdschrift voor gezondheidswetenschappen 2015 ; 93 : 286 – 7 . Google Scholar CrossRef Search ADS 10. Van Weel C . The continuous morbidity registration Nijmegen: background and history of a Dutch general practice database . Eur J Gen Pract 2008 ; 14 ( suppl 1 ): 5 – 12 . Google Scholar CrossRef Search ADS PubMed 11. Okkes I , Oskam S , van Boven K , Lamberts H . Episodes of care in family practice . Epidemiological data based on the routine use of the International Classification of Primary Care (ICPC) in the Transition Project of the Academic Medical Center/University of Amsterdam . In: Okkes IM , Oskam SK , Lamberts H (eds). ICPC in the Amsterdam Transition Project Amsterdam (cd-rom), 1995–2003 . Amsterdam: Academic Medical Center/University of Amsterdam, Department of Family Medicine, 2005. 12. Soler JK , Okkes I , Oskam S , et al. ; Transition Project . An international comparative family medicine study of the Transition Project data from the Netherlands, Malta and Serbia. Is family medicine an international discipline? Comparing incidence and prevalence rates of reasons for encounter and diagnostic titles of episodes of care across populations . Fam Pract 2012 ; 29 : 283 – 98 . Google Scholar CrossRef Search ADS PubMed 13. Soler JK , Okkes I , Wood M , Lamberts H . The coming of age of ICPC: celebrating the 21st birthday of the International Classification of Primary Care . Fam Pract 2008 ; 25 : 312 – 7 . Google Scholar CrossRef Search ADS PubMed 14. Lamberts H , Okkes I. ICPC-2, International Classification of Primary Care . Oxford: Oxford University Press, 1998 . 15. Hofmans-Okkes I , Lamberts H . Longitudinal research in general practice. The importance of including both patients’ and physicians’ perspectives on medical events . Scand J Prim Health Care Suppl 1993 ; 2 : 42 – 8 . Google Scholar CrossRef Search ADS PubMed 16. Lamberts H , Hofmans-Okkes I . Episode of care: a core concept in family practice . J Fam Pract 1996 ; 42 : 161 – 7 . Google Scholar PubMed 17. Soler JK , Okkes I . Reasons for encounter and symptom diagnoses: a superior description of patients’ problems in contrast to medically unexplained symptoms (MUS) . Fam Pract 2012 ; 29 : 272 – 82 . Google Scholar CrossRef Search ADS PubMed 18. van Boven K , Lucassen P , van Ravesteijn H , et al. Do unexplained symptoms predict anxiety or depression? Ten-year data from a practice-based research network . Br J Gen Pract Jun 2011; 61(587): e316 – 25 . © The Author(s) 2018. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Family Practice Oxford University Press

Change in frequency of patient requests for diagnostic screening and interventions during primary care encounters from 1985 to 2014

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Abstract

Abstract Background The reason why patients contact a care provider, the reason for encounter (RFE), reflects patients’ personal needs and expectations regarding medical care. RFEs can be symptoms or complaints, but can also be requests for diagnostic or therapeutic interventions. Objectives Over the past 30 years, we aim to analyse the frequency with which patients consult a GP to request an intervention, and to analyse the impact of these requests on the subsequent diagnostic process. Methods We included all patients with a request for diagnostics, medication prescription or referral from 1985 to 2014. We analysed the number of requests, granted requests and interventions originating from a request. We compared the final diagnosis (symptom or disease diagnosis) between patients with and without a request. Design and Setting This is a retrospective cohort study with data from Family Medicine Network, a Dutch primary healthcare registration network. Results Over time, patients more often present to their GP with a request for intervention. GPs are increasingly compliant with these requests. Patients presenting with a request for intervention are more likely to be diagnosed with a symptom rather than a disease. Conclusion This study provides insight into the changes in patients’ and GPs’ behaviour and patients’ influence on the medical process, and confirms the clinical relevance of the RFE. This study could support GPs in daily practice when deciding whether or not to grant a request. International Classification of Primary Care, patients’ request, primary health care, reason for encounter, symptom diagnosis Introduction To provide individualized care, GPs should be aware of the reason why the patient seeks medical care, the so-called reason for encounter (RFE). The RFE reflects the patients’ personal needs and expectations regarding medical care. The RFE is not influenced by interpretation of the care provider. Ignoring the RFE leads to a loss of important information and results in underestimating the healthcare needed for a patient (1–5). The RFE can be classified as a symptom (e.g. headache), a disease (e.g. migraine) or a request [e.g. referral (1)]. GPs’ compliance with patients’ requests is high: when patients ask for medication or a blood test, it is often performed (2–5). Being aware of the RFE improves the diagnostic process, which is an important task of GPs (6,7). A previous study identified six RFEs with a high predictive value for colorectal cancer [CRC (7)]. A couple of months prior to the diagnosis, patients presenting with tiredness, anaemia, abdominal pain, rectal bleeding, constipation or weight loss as RFE had a higher likelihood and odds ratio for CRC which may have high predictive power. The relation between patient’s RFE, diagnosis and GPs’ interventions provides more insight into the medical process. In this study, we focused on the RFEs in which patients request for a diagnostic or therapeutic intervention. In our thorough literature review, no information was found on the request for interventions as RFE. We aim to analyse whether the frequency with which patients consult a GP to request an intervention has historically changed over the last three decades. Therefore, we investigated the changes in number of requests, the percentage of GP’s compliance with a request and the percentage of interventions originating from a request. Furthermore, we analysed the influence of these requests on the subsequent diagnostic process: does the final diagnosis differ between patients who present with a symptom/complaint combined with a request and patients who present with the same symptom/complaint without a request? Methods Design and data source We performed a retrospective cohort study, using data from the Family Medicine Network (FaMe-net), a primary health care registration network in The Netherlands (8,9). FaMe-net is a fusion between two important historical registration networks, the Continuous Morbidity Registration (10) and the Transition Project (11,12). Within this network, all encounters between GPs and patients are registered since 1971. In total, 21 general practices and 68 GPs participated in this network over the last 30 years (11,12). In the first decade, 17 practices and 37 GPs participated from which 29 GPs participated for 1 year and 7 for more than 8 years. In the last 20 years, 6 practices and 11 GPs participated from which 9 GPs for 20 years. Participating practices register RFE, diagnosis and interventions for all patient encounters according to the International Classification of Primary Care [ICPC (13–15)]. Clear agreements have been made for coding RFE, diagnosis and interventions. Participating GPs have regular meetings to maintain quality of registering, discuss coding problems and receive feedback on their coding. Moreover, monthly, they fill in a questionnaire with immediate feedback about how to code several cases. Overall, participating GPs have special interest in primary care research. They register the RFE as close to the patients’ own words as possible. Interpretation of the GP is not allowed in the RFE. For example, when a patient comes in for tiredness and the GP may deem a blood test is necessary, this blood test is not coded as RFE. However, when the patient presents with ‘I am so tired, can I get a blood test?’, then both tiredness and request for a blood test are coded as RFE. Patient encounters are categorized into episodes of care. An episode of care is defined as ‘a health problem in an individual from the first presentation until the completion of the last encounter’. For example, a patient presenting with tiredness is diagnosed and treated for anaemia after a blood test. An episode of care encloses all contacts related to the health problem (in this case anaemia) and the title of the episode of care (diagnostic label) may be modified over time [in this case from tiredness to anaemia (2,16)]. Population and procedure We included all patients who visited their general practice with a request for an intervention as RFE between 1 January 1985 and 31 December 2014. We excluded telephone consultations (as these were not registered in 1985–1995), repeat prescriptions and administrative contacts. We only investigated the first encounter of an episode of care, because the RFE in follow-up encounters might be influenced by the GP. For example, when the GP suggests in the first encounter to refer to another care provider when it is not getting better after several weeks, the patient might ask for this referral in the next encounter. We divided the study period into three periods of 10 years: 1985–1994 (period 1), 1995–2004 (period 2) and 2005–2014 (period 3). The ICPC includes 18 codes for requests for intervention, of which we included seven based on relevance and frequency (Fig. 1). The excluded codes are almost never requested for by patients as RFE in the first consultation of an episode of care. Intervention codes *33 and *34 were analysed together, because almost all *33 are immunological blood tests. For each time period, we analysed the total number (n) and the number per 1000 patient years of requests as RFE and the actual intervention(s) performed by the GP in the same encounter. We defined that the GP was compliant with the request if the actual intervention was similar to the RFE in the same encounter. To investigate whether GPs’ interventions resulted from patients’ prior explicit request, we analysed the interventions performed by the GP and whether this was preceded by patient’s request for this intervention. Figure 1. View largeDownload slide Included requests for interventions during primary care encounters from 1985 to 2014 Figure 1. View largeDownload slide Included requests for interventions during primary care encounters from 1985 to 2014 To investigate the difference in diagnoses between patients who present with a request as RFE combined with a symptom/complaint and patients with the same symptom/complaint but without a request, we used data from the last 20 years. We excluded the first 10 years, because in that period many GPs only registered for 1 year. In the last 20 years, most of the GPs registered for more than 15 years and as a result, the outcome is less affected by changes of the GPs. We selected all encounters in which patients requested an intervention as RFE and analysed which other RFEs were coded in the same encounter (e.g. a request for a urine test combined with the symptom painful urination as other RFE). Subsequently, we selected all these other RFEs with a cut-off value of n = 50 over the last 20 years. Patients with a combination of a request for intervention and another RFE were compared with patients presenting with this other RFE without a request. We compared the final diagnosis in both groups, making a distinction between a symptom diagnosis (ICPC 1–23 or 29) and a disease diagnosis (ICPC 70–99). Symptom diagnoses are given when the relevant diagnostic criteria for a disease are not met (17,18). Statistical analysis We compared the number of RFEs and interventions between the three time periods by calculating rates (number per 1000 patient years) and rate ratios comparing periods 1 and 2 with period 3. Confidence intervals were determined by using Taylor series. We performed crosstab analyses to compare GPs’ compliance with patients’ requests between time periods, to compare the number of interventions with a preceding patients’ request between time periods and to determine differences in diagnosis between patients with or without a request. Chi-square tests and odds ratios were calculated. Data were analysed using OpenEpi version 3.01 and IBM SPSS Statistics version 22.0. Results Patient characteristics Table 1 shows included patients’ characteristics for each time period. Patient years are presented to compare these periods. Period 2 contains the most patient years, while period 3 contains the highest number of encounters. Age and gender distribution is equal over the time periods. Table 1. Patient characteristics during primary care encounters from 1985 to 2014 Period 1: 1985–94 Period 2: 1995–2004 Period 3: 2005–14 Number of patients 99332 151296 143787 Gender Male 46981 (47.3%) 73415 (48.5%) 69926 (48.6%) Female 52351 (52.7%) 77881(51.5%) 73861 (51.4%) Age 0–4 6071 (6.1%) 9672 (6.4%) 8516 (5.9%) 5–14 9769 (9.8%) 19192 (12.7%) 17509 (12.2%) 15–24 13103 (13.2%) 16412 (10.8%) 16149 (11.2%) 25–44 32522 (32.7%) 47459 (31.4%) 37362 (26%) 45–64 18455 (18.6%) 35647 (23.6%) 40542 (28.2%) 65–74 10925 (11%) 11538 (7.6%) 11697 (8.1%) 75+ 8487 (8.5%) 11376 (7.5%) 12012 (8.4%) Patient years 88306 142159 135548 Number of encounters Total 266309 393742 436739 Number per patient yeara (95% CI) 3.004 (3.016–3.027) 2.761 (2.77–2.778) 3.22 (3.229–3.239) Period 1: 1985–94 Period 2: 1995–2004 Period 3: 2005–14 Number of patients 99332 151296 143787 Gender Male 46981 (47.3%) 73415 (48.5%) 69926 (48.6%) Female 52351 (52.7%) 77881(51.5%) 73861 (51.4%) Age 0–4 6071 (6.1%) 9672 (6.4%) 8516 (5.9%) 5–14 9769 (9.8%) 19192 (12.7%) 17509 (12.2%) 15–24 13103 (13.2%) 16412 (10.8%) 16149 (11.2%) 25–44 32522 (32.7%) 47459 (31.4%) 37362 (26%) 45–64 18455 (18.6%) 35647 (23.6%) 40542 (28.2%) 65–74 10925 (11%) 11538 (7.6%) 11697 (8.1%) 75+ 8487 (8.5%) 11376 (7.5%) 12012 (8.4%) Patient years 88306 142159 135548 Number of encounters Total 266309 393742 436739 Number per patient yeara (95% CI) 3.004 (3.016–3.027) 2.761 (2.77–2.778) 3.22 (3.229–3.239) CI, confidence interval. aA patient year is a corrected year: if a patient is subscribed 10 years to the practice, then this patient contributes 10 patient years, and if a patient is subscribed for only 1 month, then this patient contributes 1/12 patient years to the total amount of patient years. View Large Table 1. Patient characteristics during primary care encounters from 1985 to 2014 Period 1: 1985–94 Period 2: 1995–2004 Period 3: 2005–14 Number of patients 99332 151296 143787 Gender Male 46981 (47.3%) 73415 (48.5%) 69926 (48.6%) Female 52351 (52.7%) 77881(51.5%) 73861 (51.4%) Age 0–4 6071 (6.1%) 9672 (6.4%) 8516 (5.9%) 5–14 9769 (9.8%) 19192 (12.7%) 17509 (12.2%) 15–24 13103 (13.2%) 16412 (10.8%) 16149 (11.2%) 25–44 32522 (32.7%) 47459 (31.4%) 37362 (26%) 45–64 18455 (18.6%) 35647 (23.6%) 40542 (28.2%) 65–74 10925 (11%) 11538 (7.6%) 11697 (8.1%) 75+ 8487 (8.5%) 11376 (7.5%) 12012 (8.4%) Patient years 88306 142159 135548 Number of encounters Total 266309 393742 436739 Number per patient yeara (95% CI) 3.004 (3.016–3.027) 2.761 (2.77–2.778) 3.22 (3.229–3.239) Period 1: 1985–94 Period 2: 1995–2004 Period 3: 2005–14 Number of patients 99332 151296 143787 Gender Male 46981 (47.3%) 73415 (48.5%) 69926 (48.6%) Female 52351 (52.7%) 77881(51.5%) 73861 (51.4%) Age 0–4 6071 (6.1%) 9672 (6.4%) 8516 (5.9%) 5–14 9769 (9.8%) 19192 (12.7%) 17509 (12.2%) 15–24 13103 (13.2%) 16412 (10.8%) 16149 (11.2%) 25–44 32522 (32.7%) 47459 (31.4%) 37362 (26%) 45–64 18455 (18.6%) 35647 (23.6%) 40542 (28.2%) 65–74 10925 (11%) 11538 (7.6%) 11697 (8.1%) 75+ 8487 (8.5%) 11376 (7.5%) 12012 (8.4%) Patient years 88306 142159 135548 Number of encounters Total 266309 393742 436739 Number per patient yeara (95% CI) 3.004 (3.016–3.027) 2.761 (2.77–2.778) 3.22 (3.229–3.239) CI, confidence interval. aA patient year is a corrected year: if a patient is subscribed 10 years to the practice, then this patient contributes 10 patient years, and if a patient is subscribed for only 1 month, then this patient contributes 1/12 patient years to the total amount of patient years. View Large Requests for interventions over time Table 2 shows the trend in number of patients with a request for intervention as RFE and GPs’ compliance with these requests over the past 30 years. We found a significant increase for most requests over time (P < 0.001). For example, patients’ request for blood test increased from 11.4 to 23 per 1000 patient years [rate ratio = 2.02; confidence interval (CI) = 1.89–2.17; Supplementary Tables S1 and S2]. We found only one decrease in requests over time: patients’ request for referral to another primary care provider (rate ratio = 0.71; CI = 0.66–0.76; Supplementary Tables S1 and S2) decreased in the past 20 years. Table 2. Patients’ requests for interventions, GPs’ compliance with these interventions, and number of interventions preceded by patients’ request during primary care encounters from 1985 to 2014 Intervention Time perioda Presented as RFE per 1000 patient years (n) GPs’ compliance % Total number of intervention per 1000 patient years (n) Originally resulting from a request % Blood test 1 11.4* (1008) 90.3* 120.3* (10626) 8.6* 2 23.3 (3312) 91.7* 136.1* (19345) 15.7* 3 23 (3132) 94.1 225.9 (30616) 9.6 Urine test 1 1.8* (161) 88.2* 53.7* (4743) 3.0* 2 18.3* (2602) 94.1* 61.1* (8692) 28.2* 3 48.4 (6555) 100.0 109.7 (14871) 45.0 Radiology/imaging 1 1.8* (162) 70.4* 52.6* (4646) 2.5* 2 3.7* (519) 76.1* 61* (8669) 4.6 3 4.3 (577) 84.4 90.3 (12235) 4.0 Medication prescription 1 48.1* (4246) 91.0* 819.6* (72372) 5.3* 2 57.6 (8188) 93.7 669.4* (95158) 8.1* 3 58.9 (7979) 93.4 631.4 (85580) 8.7 Referral to other primary care provider 1 5.7* (506) 79.2* 65.8* (5812) 6.9* 2 14.6* (2078) 89.2 85.2* (12119) 15.3* 3 10.3 (1402) 89.4 79.4 (10759) 11.6 Referral to secondary care 1 10.1* (895) 68.8* 97.8* (8640) 7.1* 2 11.9* (1690) 81.1* 93.5* (13296) 10.3 3 16.2 (2192) 88.5 137.7 (18663) 10.4 Intervention Time perioda Presented as RFE per 1000 patient years (n) GPs’ compliance % Total number of intervention per 1000 patient years (n) Originally resulting from a request % Blood test 1 11.4* (1008) 90.3* 120.3* (10626) 8.6* 2 23.3 (3312) 91.7* 136.1* (19345) 15.7* 3 23 (3132) 94.1 225.9 (30616) 9.6 Urine test 1 1.8* (161) 88.2* 53.7* (4743) 3.0* 2 18.3* (2602) 94.1* 61.1* (8692) 28.2* 3 48.4 (6555) 100.0 109.7 (14871) 45.0 Radiology/imaging 1 1.8* (162) 70.4* 52.6* (4646) 2.5* 2 3.7* (519) 76.1* 61* (8669) 4.6 3 4.3 (577) 84.4 90.3 (12235) 4.0 Medication prescription 1 48.1* (4246) 91.0* 819.6* (72372) 5.3* 2 57.6 (8188) 93.7 669.4* (95158) 8.1* 3 58.9 (7979) 93.4 631.4 (85580) 8.7 Referral to other primary care provider 1 5.7* (506) 79.2* 65.8* (5812) 6.9* 2 14.6* (2078) 89.2 85.2* (12119) 15.3* 3 10.3 (1402) 89.4 79.4 (10759) 11.6 Referral to secondary care 1 10.1* (895) 68.8* 97.8* (8640) 7.1* 2 11.9* (1690) 81.1* 93.5* (13296) 10.3 3 16.2 (2192) 88.5 137.7 (18663) 10.4 RFE, reason for encounter. aPeriod 1: 1985–1994; period 2: 1995–2004; period 3: 2005–2014. *Significant difference (P < 0.05) compared with period 3, according to chi-square tests. View Large Table 2. Patients’ requests for interventions, GPs’ compliance with these interventions, and number of interventions preceded by patients’ request during primary care encounters from 1985 to 2014 Intervention Time perioda Presented as RFE per 1000 patient years (n) GPs’ compliance % Total number of intervention per 1000 patient years (n) Originally resulting from a request % Blood test 1 11.4* (1008) 90.3* 120.3* (10626) 8.6* 2 23.3 (3312) 91.7* 136.1* (19345) 15.7* 3 23 (3132) 94.1 225.9 (30616) 9.6 Urine test 1 1.8* (161) 88.2* 53.7* (4743) 3.0* 2 18.3* (2602) 94.1* 61.1* (8692) 28.2* 3 48.4 (6555) 100.0 109.7 (14871) 45.0 Radiology/imaging 1 1.8* (162) 70.4* 52.6* (4646) 2.5* 2 3.7* (519) 76.1* 61* (8669) 4.6 3 4.3 (577) 84.4 90.3 (12235) 4.0 Medication prescription 1 48.1* (4246) 91.0* 819.6* (72372) 5.3* 2 57.6 (8188) 93.7 669.4* (95158) 8.1* 3 58.9 (7979) 93.4 631.4 (85580) 8.7 Referral to other primary care provider 1 5.7* (506) 79.2* 65.8* (5812) 6.9* 2 14.6* (2078) 89.2 85.2* (12119) 15.3* 3 10.3 (1402) 89.4 79.4 (10759) 11.6 Referral to secondary care 1 10.1* (895) 68.8* 97.8* (8640) 7.1* 2 11.9* (1690) 81.1* 93.5* (13296) 10.3 3 16.2 (2192) 88.5 137.7 (18663) 10.4 Intervention Time perioda Presented as RFE per 1000 patient years (n) GPs’ compliance % Total number of intervention per 1000 patient years (n) Originally resulting from a request % Blood test 1 11.4* (1008) 90.3* 120.3* (10626) 8.6* 2 23.3 (3312) 91.7* 136.1* (19345) 15.7* 3 23 (3132) 94.1 225.9 (30616) 9.6 Urine test 1 1.8* (161) 88.2* 53.7* (4743) 3.0* 2 18.3* (2602) 94.1* 61.1* (8692) 28.2* 3 48.4 (6555) 100.0 109.7 (14871) 45.0 Radiology/imaging 1 1.8* (162) 70.4* 52.6* (4646) 2.5* 2 3.7* (519) 76.1* 61* (8669) 4.6 3 4.3 (577) 84.4 90.3 (12235) 4.0 Medication prescription 1 48.1* (4246) 91.0* 819.6* (72372) 5.3* 2 57.6 (8188) 93.7 669.4* (95158) 8.1* 3 58.9 (7979) 93.4 631.4 (85580) 8.7 Referral to other primary care provider 1 5.7* (506) 79.2* 65.8* (5812) 6.9* 2 14.6* (2078) 89.2 85.2* (12119) 15.3* 3 10.3 (1402) 89.4 79.4 (10759) 11.6 Referral to secondary care 1 10.1* (895) 68.8* 97.8* (8640) 7.1* 2 11.9* (1690) 81.1* 93.5* (13296) 10.3 3 16.2 (2192) 88.5 137.7 (18663) 10.4 RFE, reason for encounter. aPeriod 1: 1985–1994; period 2: 1995–2004; period 3: 2005–2014. *Significant difference (P < 0.05) compared with period 3, according to chi-square tests. View Large GPs are compliant with most requests (range: 68.8%–93.7%; Table 2). This compliance increases significantly over time for all requests. Table 2 also shows the total number of each intervention over time. Over the past 30 years, we found an increase in total blood tests, urine tests, radiology and referrals to primary and secondary care and a decrease in medication prescription. The percentages of interventions preceding by patients’ requests significantly increase when comparing periods 1 and 3, while we see smaller increases or even decreases when comparing periods 2 and 3. Difference in final diagnosis in patients with a request Table 3 shows the difference in final symptom diagnoses between patients presenting with a symptom/complaint combined with a request and patients presenting with the same symptom/complaint without a request. For example, the combination of a request for a blood test and vertigo/dizziness as RFE occurred in 187 cases and resulted in a final symptom diagnosis in 79.1%. Patients presenting with vertigo/dizziness without a request for a blood test were diagnosed with a final symptom diagnosis in 54.5%. Overall, when patients requested an intervention for blood test, radiology, medication prescription and referral to primary or secondary care in addition to a symptom/complaint, a higher likelihood of a final symptom diagnosis was found compared with patients presenting with the same symptom/complaint without a request. In contrary, for patients requesting a urine test in addition to a symptom/complaint, a lower likelihood of a final symptom diagnosis was found compared with patients presenting with the same symptom/complaint without this request. Most of these patients were diagnosed with the disease diagnosis cystitis. Table 3. Final symptom diagnoses between patients with and without a request during primary care encounters from 1985 to 2014 First RFE Second RFE Prevalence of second RFE per 1000 patient years (n) Percentage of final symptom diagnoses in patients with a request (n) Percentage of final symptom diagnoses in patients without a request (n) ORa CIb (95%) P value Blood test Headache 0.2 (56) 91.1 (51) 60.7 (5131) 6.61 2.64–16.58 <0.001* Vertigo/dizziness 0.7 (187) 79.1 (148) 54.5 (3377) 3.17 2.22–4.53 <0.001* Weakness/tiredness, general 3.4 (951) 87.6 (833) 70.2 (7591) 2.99 2.46–3.64 <0.001* Fear of AIDS 0.2 (59) 5.1 (3) 2.5 (2) 2.11 0.34–13.08 0.410 Excessive thirst 0.3 (72) 76.4 (55) 67.7 (285) 1.54 0.86–2.76 0.141 Prevention 0.3 (85) 3.5 (3) 3 (48) 1.19 0.36–3.91 0.772 Risk factor cardiovascular disease 0.2 (67) 80.6 (54) 87 (321) 0.62 0.32–1.22 0.165 Fear of an endocrine/metabolic disease 0.4 (114) 1.1 (16) 14.8 (56) 0.06 0.04–0.11 <0.001* Urine test Fever 0.4 (107) 31.8 (34) 15.1 (1966) 2.61 1.73–3.93 <0.001* Cystitis 1.8 (505) 8.3 (42) 4.7 (101) 1.86 1.28–2.70 0.001* Abdominal pain, generalized 0.3 (82) 68.3 (56) 56.7 (1972) 1.65 1.03–2.64 0.035* Painful urination 9.1 (2538) 31.6 (802) 24.8 (801) 1.40 1.25–1.57 <0.001* Urine complaints, other 0.7 (193) 59.6 (115) 64.1 (141) 0.83 0.56–1.23 0.347 Flank complaints 0.4 (116) 58.6 (68) 64.4 (1071) 0.78 0.53–1.15 0.210 Frequent/urgent urination 7.4 (2067) 35.4 (731) 41.9 (1470) 0.76 0.68–0.85 <0.001* Abdominal pain, localized 2.8 (783) 54.7 (428) 63.9 (6606) 0.68 0.56–0.79 <0.001* Blood in urine 0.7 (195) 36.4 (71) 52.8 (374) 0.51 0.37–0.71 <0.001* Incontinence 0.3 (76) 63.2 (48) 79 (793) 0.46 0.28–0.75 <0.001* Low back complaints 0.5 (140) 63.6 (89) 80.8 (7927) 0.41 0.29–0.59 <0.001* Fear of a urinary disease 0.6 (168) 4.2 (7) 12.4 (93) 0.31 0.14–0.68 0.002* Back complaints 0.2 (58) 55.2 (32) 81.1 (3058) 0.29 0.17–0.49 <0.001* Radiology/imaging Knee complaints 0.2 (65) 63.1 (41) 50.7 (4070) 1.66 1.00–2.75 0.047* Low back complaints 0.3 (74) 83.8 (62) 80.6 (8016) 1.25 0.67–2.32 0.485 Medication prescription Constipation 0.4 (102) 99 (1) 90.5 (1915) 10.6 1.47–76.40 0.003* Disturbances of sleep/insomnia 1.4 (383) 96.1 (368) 88.1 (2097) 3.23 1.95–5.65 <0.001* Feeling anxious/nervous/tense 0.7 (206) 89.8 (185) 76.7 (2418) 2.67 1.69–4.23 <0.001* Low back complaints 0.6 (154) 91.6 (141) 80.4 (7875) 2.64 1.49–4.67 0.001* Cough 2.2 (606) 43.6 (264) 28.2 (8128) 1.97 1.67–2.31 <0.001* Headache 0.4 (115) 71.3 (82) 60.7 (5100) 1.61 1.07–2.41 0.021* Pruritis 0.3 (90) 36.7 (22) 28.7 (2117) 1.44 0.94–2.21 0.097 Local redness/erythema/rash 0.4 (107) 14 (15) 13.8 (2116) 1.0 0.59–1.77 0.940 Acute upper respiratory infection 0.6 (159) 6.9 (11) 7.9 (526) 0.87 0.47–1.60 0.647 Shortness of breath/dyspnoea 0.3 (89) 22.5 (20) 29 (2456) 0.71 0.43–1.17 0.177 Throat complaints 0.5 (152) 25.7 (39) 34.3 (4188) 0.66 0.46–0.95 0.026* Acute/chronic sinusitis 0.5 (129) 2.3 (3) 4.6 (62) 0.50 0.15–1.61 0.235 Prevention 0.5 (133) 1.5 (2) 3.1 (49) 0.47 0.11–1.96 0.427c Oral contraceptive 0.7 (196) 2 (4) 4.8 (48) 0.42 0.15–1.12 0.086 Dermatophytosis 0.5 (141) 0.7 (1) 1.9 (44) 0.38 0.05–2.76 0.319 Cystitis 0.6 (159) 1.3 (2) 5.6 (141) 0.22 0.053–0.88 0.018* Painful urination 0.4 (100) 5 (5) 28.2 (1598) 0.13 0.054–0.33 <0.001* Referral to other primary care provider Neck complaints 1.4 (402) 96.8 (389) 84.3 (4911) 5.57 3.19–9.72 <0.001* Shoulder complaints 0.6 (180) 85 (153) 50.6 (3843) 5.54 3.67–8.35 <0.001* Back complaints 0.4 (110) 95.5 (105) 80.2 (2985) 5.17 2.10–12.73 <0.001* Low back complaints 1.2 (330) 94.5 (312) 80.1 (7704) 4.30 2.67–6.94 <0.001* Foot/toe complaints 0.2 (62) 75.8 (47) 47.2 (4164) 3.50 1.96–6.27 <0.001* Arm complaints 0.2 (51) 78.4 (40) 52.3 (2074) 3.32 1.67–6.49 <0.001* Feeling depressed 0.2 (52) 78.8 (41) 58.8 (1196) 2.61 1.33–5.10 0.004* Knee complaints 0.2 (55) 72.7 (40) 50.7 (4071) 2.60 1.43–4.71 0.001* Leg/thigh complaints 0.2 (54) 70.4 (38) 53.4 (3869) 2.07 1.15–3.73 0.013* Feeling anxious/nervous/tense 0.2 (55) 87.3 (48) 77.4 (2555) 2.00 0.90–4.45 0.081 Relation problem partners 0.3 (81) 97.5 (79) 97.2 (840) 1.13 0.26–4.86 0.871 Overweight (BMI < 30) 0.2 (56) 0 (0) 2.7 (15) 1.10 1.08–1.13 0.212 Referral to secondary care Hearing complaints 0.2 (69) 46.4 (64) 13.9 (2026) 5.34 3.81–7.49 <0.001* Local swelling/papule/lump/mass 0.4 (99) 43.4 (86) 28 (7588) 1.98 1.49–2.63 <0.001* Visual complaints, other 0.4 (105) 66.7 (70) 54.8 (1018) 1.65 1.09–2.50 0.017* Nevus/mole 0.3 (71) 0 (0) 1.4 (72) 1.03 1.02–1.03 0.153 First RFE Second RFE Prevalence of second RFE per 1000 patient years (n) Percentage of final symptom diagnoses in patients with a request (n) Percentage of final symptom diagnoses in patients without a request (n) ORa CIb (95%) P value Blood test Headache 0.2 (56) 91.1 (51) 60.7 (5131) 6.61 2.64–16.58 <0.001* Vertigo/dizziness 0.7 (187) 79.1 (148) 54.5 (3377) 3.17 2.22–4.53 <0.001* Weakness/tiredness, general 3.4 (951) 87.6 (833) 70.2 (7591) 2.99 2.46–3.64 <0.001* Fear of AIDS 0.2 (59) 5.1 (3) 2.5 (2) 2.11 0.34–13.08 0.410 Excessive thirst 0.3 (72) 76.4 (55) 67.7 (285) 1.54 0.86–2.76 0.141 Prevention 0.3 (85) 3.5 (3) 3 (48) 1.19 0.36–3.91 0.772 Risk factor cardiovascular disease 0.2 (67) 80.6 (54) 87 (321) 0.62 0.32–1.22 0.165 Fear of an endocrine/metabolic disease 0.4 (114) 1.1 (16) 14.8 (56) 0.06 0.04–0.11 <0.001* Urine test Fever 0.4 (107) 31.8 (34) 15.1 (1966) 2.61 1.73–3.93 <0.001* Cystitis 1.8 (505) 8.3 (42) 4.7 (101) 1.86 1.28–2.70 0.001* Abdominal pain, generalized 0.3 (82) 68.3 (56) 56.7 (1972) 1.65 1.03–2.64 0.035* Painful urination 9.1 (2538) 31.6 (802) 24.8 (801) 1.40 1.25–1.57 <0.001* Urine complaints, other 0.7 (193) 59.6 (115) 64.1 (141) 0.83 0.56–1.23 0.347 Flank complaints 0.4 (116) 58.6 (68) 64.4 (1071) 0.78 0.53–1.15 0.210 Frequent/urgent urination 7.4 (2067) 35.4 (731) 41.9 (1470) 0.76 0.68–0.85 <0.001* Abdominal pain, localized 2.8 (783) 54.7 (428) 63.9 (6606) 0.68 0.56–0.79 <0.001* Blood in urine 0.7 (195) 36.4 (71) 52.8 (374) 0.51 0.37–0.71 <0.001* Incontinence 0.3 (76) 63.2 (48) 79 (793) 0.46 0.28–0.75 <0.001* Low back complaints 0.5 (140) 63.6 (89) 80.8 (7927) 0.41 0.29–0.59 <0.001* Fear of a urinary disease 0.6 (168) 4.2 (7) 12.4 (93) 0.31 0.14–0.68 0.002* Back complaints 0.2 (58) 55.2 (32) 81.1 (3058) 0.29 0.17–0.49 <0.001* Radiology/imaging Knee complaints 0.2 (65) 63.1 (41) 50.7 (4070) 1.66 1.00–2.75 0.047* Low back complaints 0.3 (74) 83.8 (62) 80.6 (8016) 1.25 0.67–2.32 0.485 Medication prescription Constipation 0.4 (102) 99 (1) 90.5 (1915) 10.6 1.47–76.40 0.003* Disturbances of sleep/insomnia 1.4 (383) 96.1 (368) 88.1 (2097) 3.23 1.95–5.65 <0.001* Feeling anxious/nervous/tense 0.7 (206) 89.8 (185) 76.7 (2418) 2.67 1.69–4.23 <0.001* Low back complaints 0.6 (154) 91.6 (141) 80.4 (7875) 2.64 1.49–4.67 0.001* Cough 2.2 (606) 43.6 (264) 28.2 (8128) 1.97 1.67–2.31 <0.001* Headache 0.4 (115) 71.3 (82) 60.7 (5100) 1.61 1.07–2.41 0.021* Pruritis 0.3 (90) 36.7 (22) 28.7 (2117) 1.44 0.94–2.21 0.097 Local redness/erythema/rash 0.4 (107) 14 (15) 13.8 (2116) 1.0 0.59–1.77 0.940 Acute upper respiratory infection 0.6 (159) 6.9 (11) 7.9 (526) 0.87 0.47–1.60 0.647 Shortness of breath/dyspnoea 0.3 (89) 22.5 (20) 29 (2456) 0.71 0.43–1.17 0.177 Throat complaints 0.5 (152) 25.7 (39) 34.3 (4188) 0.66 0.46–0.95 0.026* Acute/chronic sinusitis 0.5 (129) 2.3 (3) 4.6 (62) 0.50 0.15–1.61 0.235 Prevention 0.5 (133) 1.5 (2) 3.1 (49) 0.47 0.11–1.96 0.427c Oral contraceptive 0.7 (196) 2 (4) 4.8 (48) 0.42 0.15–1.12 0.086 Dermatophytosis 0.5 (141) 0.7 (1) 1.9 (44) 0.38 0.05–2.76 0.319 Cystitis 0.6 (159) 1.3 (2) 5.6 (141) 0.22 0.053–0.88 0.018* Painful urination 0.4 (100) 5 (5) 28.2 (1598) 0.13 0.054–0.33 <0.001* Referral to other primary care provider Neck complaints 1.4 (402) 96.8 (389) 84.3 (4911) 5.57 3.19–9.72 <0.001* Shoulder complaints 0.6 (180) 85 (153) 50.6 (3843) 5.54 3.67–8.35 <0.001* Back complaints 0.4 (110) 95.5 (105) 80.2 (2985) 5.17 2.10–12.73 <0.001* Low back complaints 1.2 (330) 94.5 (312) 80.1 (7704) 4.30 2.67–6.94 <0.001* Foot/toe complaints 0.2 (62) 75.8 (47) 47.2 (4164) 3.50 1.96–6.27 <0.001* Arm complaints 0.2 (51) 78.4 (40) 52.3 (2074) 3.32 1.67–6.49 <0.001* Feeling depressed 0.2 (52) 78.8 (41) 58.8 (1196) 2.61 1.33–5.10 0.004* Knee complaints 0.2 (55) 72.7 (40) 50.7 (4071) 2.60 1.43–4.71 0.001* Leg/thigh complaints 0.2 (54) 70.4 (38) 53.4 (3869) 2.07 1.15–3.73 0.013* Feeling anxious/nervous/tense 0.2 (55) 87.3 (48) 77.4 (2555) 2.00 0.90–4.45 0.081 Relation problem partners 0.3 (81) 97.5 (79) 97.2 (840) 1.13 0.26–4.86 0.871 Overweight (BMI < 30) 0.2 (56) 0 (0) 2.7 (15) 1.10 1.08–1.13 0.212 Referral to secondary care Hearing complaints 0.2 (69) 46.4 (64) 13.9 (2026) 5.34 3.81–7.49 <0.001* Local swelling/papule/lump/mass 0.4 (99) 43.4 (86) 28 (7588) 1.98 1.49–2.63 <0.001* Visual complaints, other 0.4 (105) 66.7 (70) 54.8 (1018) 1.65 1.09–2.50 0.017* Nevus/mole 0.3 (71) 0 (0) 1.4 (72) 1.03 1.02–1.03 0.153 AIDS, acquired immune deficiency syndrome; BMI, body mass index; RFE, reason for encounter aOdds ratio, the odds of having a symptom diagnoses if presenting with a symptom and a request compared to the odds of having a symptom diagnosis without a request for intervention. bConfidence interval, determined by using Taylor series. cExpected count less than 5, Fisher’s exact test was used. *P value below 0.05, according to chi-square tests. View Large Table 3. Final symptom diagnoses between patients with and without a request during primary care encounters from 1985 to 2014 First RFE Second RFE Prevalence of second RFE per 1000 patient years (n) Percentage of final symptom diagnoses in patients with a request (n) Percentage of final symptom diagnoses in patients without a request (n) ORa CIb (95%) P value Blood test Headache 0.2 (56) 91.1 (51) 60.7 (5131) 6.61 2.64–16.58 <0.001* Vertigo/dizziness 0.7 (187) 79.1 (148) 54.5 (3377) 3.17 2.22–4.53 <0.001* Weakness/tiredness, general 3.4 (951) 87.6 (833) 70.2 (7591) 2.99 2.46–3.64 <0.001* Fear of AIDS 0.2 (59) 5.1 (3) 2.5 (2) 2.11 0.34–13.08 0.410 Excessive thirst 0.3 (72) 76.4 (55) 67.7 (285) 1.54 0.86–2.76 0.141 Prevention 0.3 (85) 3.5 (3) 3 (48) 1.19 0.36–3.91 0.772 Risk factor cardiovascular disease 0.2 (67) 80.6 (54) 87 (321) 0.62 0.32–1.22 0.165 Fear of an endocrine/metabolic disease 0.4 (114) 1.1 (16) 14.8 (56) 0.06 0.04–0.11 <0.001* Urine test Fever 0.4 (107) 31.8 (34) 15.1 (1966) 2.61 1.73–3.93 <0.001* Cystitis 1.8 (505) 8.3 (42) 4.7 (101) 1.86 1.28–2.70 0.001* Abdominal pain, generalized 0.3 (82) 68.3 (56) 56.7 (1972) 1.65 1.03–2.64 0.035* Painful urination 9.1 (2538) 31.6 (802) 24.8 (801) 1.40 1.25–1.57 <0.001* Urine complaints, other 0.7 (193) 59.6 (115) 64.1 (141) 0.83 0.56–1.23 0.347 Flank complaints 0.4 (116) 58.6 (68) 64.4 (1071) 0.78 0.53–1.15 0.210 Frequent/urgent urination 7.4 (2067) 35.4 (731) 41.9 (1470) 0.76 0.68–0.85 <0.001* Abdominal pain, localized 2.8 (783) 54.7 (428) 63.9 (6606) 0.68 0.56–0.79 <0.001* Blood in urine 0.7 (195) 36.4 (71) 52.8 (374) 0.51 0.37–0.71 <0.001* Incontinence 0.3 (76) 63.2 (48) 79 (793) 0.46 0.28–0.75 <0.001* Low back complaints 0.5 (140) 63.6 (89) 80.8 (7927) 0.41 0.29–0.59 <0.001* Fear of a urinary disease 0.6 (168) 4.2 (7) 12.4 (93) 0.31 0.14–0.68 0.002* Back complaints 0.2 (58) 55.2 (32) 81.1 (3058) 0.29 0.17–0.49 <0.001* Radiology/imaging Knee complaints 0.2 (65) 63.1 (41) 50.7 (4070) 1.66 1.00–2.75 0.047* Low back complaints 0.3 (74) 83.8 (62) 80.6 (8016) 1.25 0.67–2.32 0.485 Medication prescription Constipation 0.4 (102) 99 (1) 90.5 (1915) 10.6 1.47–76.40 0.003* Disturbances of sleep/insomnia 1.4 (383) 96.1 (368) 88.1 (2097) 3.23 1.95–5.65 <0.001* Feeling anxious/nervous/tense 0.7 (206) 89.8 (185) 76.7 (2418) 2.67 1.69–4.23 <0.001* Low back complaints 0.6 (154) 91.6 (141) 80.4 (7875) 2.64 1.49–4.67 0.001* Cough 2.2 (606) 43.6 (264) 28.2 (8128) 1.97 1.67–2.31 <0.001* Headache 0.4 (115) 71.3 (82) 60.7 (5100) 1.61 1.07–2.41 0.021* Pruritis 0.3 (90) 36.7 (22) 28.7 (2117) 1.44 0.94–2.21 0.097 Local redness/erythema/rash 0.4 (107) 14 (15) 13.8 (2116) 1.0 0.59–1.77 0.940 Acute upper respiratory infection 0.6 (159) 6.9 (11) 7.9 (526) 0.87 0.47–1.60 0.647 Shortness of breath/dyspnoea 0.3 (89) 22.5 (20) 29 (2456) 0.71 0.43–1.17 0.177 Throat complaints 0.5 (152) 25.7 (39) 34.3 (4188) 0.66 0.46–0.95 0.026* Acute/chronic sinusitis 0.5 (129) 2.3 (3) 4.6 (62) 0.50 0.15–1.61 0.235 Prevention 0.5 (133) 1.5 (2) 3.1 (49) 0.47 0.11–1.96 0.427c Oral contraceptive 0.7 (196) 2 (4) 4.8 (48) 0.42 0.15–1.12 0.086 Dermatophytosis 0.5 (141) 0.7 (1) 1.9 (44) 0.38 0.05–2.76 0.319 Cystitis 0.6 (159) 1.3 (2) 5.6 (141) 0.22 0.053–0.88 0.018* Painful urination 0.4 (100) 5 (5) 28.2 (1598) 0.13 0.054–0.33 <0.001* Referral to other primary care provider Neck complaints 1.4 (402) 96.8 (389) 84.3 (4911) 5.57 3.19–9.72 <0.001* Shoulder complaints 0.6 (180) 85 (153) 50.6 (3843) 5.54 3.67–8.35 <0.001* Back complaints 0.4 (110) 95.5 (105) 80.2 (2985) 5.17 2.10–12.73 <0.001* Low back complaints 1.2 (330) 94.5 (312) 80.1 (7704) 4.30 2.67–6.94 <0.001* Foot/toe complaints 0.2 (62) 75.8 (47) 47.2 (4164) 3.50 1.96–6.27 <0.001* Arm complaints 0.2 (51) 78.4 (40) 52.3 (2074) 3.32 1.67–6.49 <0.001* Feeling depressed 0.2 (52) 78.8 (41) 58.8 (1196) 2.61 1.33–5.10 0.004* Knee complaints 0.2 (55) 72.7 (40) 50.7 (4071) 2.60 1.43–4.71 0.001* Leg/thigh complaints 0.2 (54) 70.4 (38) 53.4 (3869) 2.07 1.15–3.73 0.013* Feeling anxious/nervous/tense 0.2 (55) 87.3 (48) 77.4 (2555) 2.00 0.90–4.45 0.081 Relation problem partners 0.3 (81) 97.5 (79) 97.2 (840) 1.13 0.26–4.86 0.871 Overweight (BMI < 30) 0.2 (56) 0 (0) 2.7 (15) 1.10 1.08–1.13 0.212 Referral to secondary care Hearing complaints 0.2 (69) 46.4 (64) 13.9 (2026) 5.34 3.81–7.49 <0.001* Local swelling/papule/lump/mass 0.4 (99) 43.4 (86) 28 (7588) 1.98 1.49–2.63 <0.001* Visual complaints, other 0.4 (105) 66.7 (70) 54.8 (1018) 1.65 1.09–2.50 0.017* Nevus/mole 0.3 (71) 0 (0) 1.4 (72) 1.03 1.02–1.03 0.153 First RFE Second RFE Prevalence of second RFE per 1000 patient years (n) Percentage of final symptom diagnoses in patients with a request (n) Percentage of final symptom diagnoses in patients without a request (n) ORa CIb (95%) P value Blood test Headache 0.2 (56) 91.1 (51) 60.7 (5131) 6.61 2.64–16.58 <0.001* Vertigo/dizziness 0.7 (187) 79.1 (148) 54.5 (3377) 3.17 2.22–4.53 <0.001* Weakness/tiredness, general 3.4 (951) 87.6 (833) 70.2 (7591) 2.99 2.46–3.64 <0.001* Fear of AIDS 0.2 (59) 5.1 (3) 2.5 (2) 2.11 0.34–13.08 0.410 Excessive thirst 0.3 (72) 76.4 (55) 67.7 (285) 1.54 0.86–2.76 0.141 Prevention 0.3 (85) 3.5 (3) 3 (48) 1.19 0.36–3.91 0.772 Risk factor cardiovascular disease 0.2 (67) 80.6 (54) 87 (321) 0.62 0.32–1.22 0.165 Fear of an endocrine/metabolic disease 0.4 (114) 1.1 (16) 14.8 (56) 0.06 0.04–0.11 <0.001* Urine test Fever 0.4 (107) 31.8 (34) 15.1 (1966) 2.61 1.73–3.93 <0.001* Cystitis 1.8 (505) 8.3 (42) 4.7 (101) 1.86 1.28–2.70 0.001* Abdominal pain, generalized 0.3 (82) 68.3 (56) 56.7 (1972) 1.65 1.03–2.64 0.035* Painful urination 9.1 (2538) 31.6 (802) 24.8 (801) 1.40 1.25–1.57 <0.001* Urine complaints, other 0.7 (193) 59.6 (115) 64.1 (141) 0.83 0.56–1.23 0.347 Flank complaints 0.4 (116) 58.6 (68) 64.4 (1071) 0.78 0.53–1.15 0.210 Frequent/urgent urination 7.4 (2067) 35.4 (731) 41.9 (1470) 0.76 0.68–0.85 <0.001* Abdominal pain, localized 2.8 (783) 54.7 (428) 63.9 (6606) 0.68 0.56–0.79 <0.001* Blood in urine 0.7 (195) 36.4 (71) 52.8 (374) 0.51 0.37–0.71 <0.001* Incontinence 0.3 (76) 63.2 (48) 79 (793) 0.46 0.28–0.75 <0.001* Low back complaints 0.5 (140) 63.6 (89) 80.8 (7927) 0.41 0.29–0.59 <0.001* Fear of a urinary disease 0.6 (168) 4.2 (7) 12.4 (93) 0.31 0.14–0.68 0.002* Back complaints 0.2 (58) 55.2 (32) 81.1 (3058) 0.29 0.17–0.49 <0.001* Radiology/imaging Knee complaints 0.2 (65) 63.1 (41) 50.7 (4070) 1.66 1.00–2.75 0.047* Low back complaints 0.3 (74) 83.8 (62) 80.6 (8016) 1.25 0.67–2.32 0.485 Medication prescription Constipation 0.4 (102) 99 (1) 90.5 (1915) 10.6 1.47–76.40 0.003* Disturbances of sleep/insomnia 1.4 (383) 96.1 (368) 88.1 (2097) 3.23 1.95–5.65 <0.001* Feeling anxious/nervous/tense 0.7 (206) 89.8 (185) 76.7 (2418) 2.67 1.69–4.23 <0.001* Low back complaints 0.6 (154) 91.6 (141) 80.4 (7875) 2.64 1.49–4.67 0.001* Cough 2.2 (606) 43.6 (264) 28.2 (8128) 1.97 1.67–2.31 <0.001* Headache 0.4 (115) 71.3 (82) 60.7 (5100) 1.61 1.07–2.41 0.021* Pruritis 0.3 (90) 36.7 (22) 28.7 (2117) 1.44 0.94–2.21 0.097 Local redness/erythema/rash 0.4 (107) 14 (15) 13.8 (2116) 1.0 0.59–1.77 0.940 Acute upper respiratory infection 0.6 (159) 6.9 (11) 7.9 (526) 0.87 0.47–1.60 0.647 Shortness of breath/dyspnoea 0.3 (89) 22.5 (20) 29 (2456) 0.71 0.43–1.17 0.177 Throat complaints 0.5 (152) 25.7 (39) 34.3 (4188) 0.66 0.46–0.95 0.026* Acute/chronic sinusitis 0.5 (129) 2.3 (3) 4.6 (62) 0.50 0.15–1.61 0.235 Prevention 0.5 (133) 1.5 (2) 3.1 (49) 0.47 0.11–1.96 0.427c Oral contraceptive 0.7 (196) 2 (4) 4.8 (48) 0.42 0.15–1.12 0.086 Dermatophytosis 0.5 (141) 0.7 (1) 1.9 (44) 0.38 0.05–2.76 0.319 Cystitis 0.6 (159) 1.3 (2) 5.6 (141) 0.22 0.053–0.88 0.018* Painful urination 0.4 (100) 5 (5) 28.2 (1598) 0.13 0.054–0.33 <0.001* Referral to other primary care provider Neck complaints 1.4 (402) 96.8 (389) 84.3 (4911) 5.57 3.19–9.72 <0.001* Shoulder complaints 0.6 (180) 85 (153) 50.6 (3843) 5.54 3.67–8.35 <0.001* Back complaints 0.4 (110) 95.5 (105) 80.2 (2985) 5.17 2.10–12.73 <0.001* Low back complaints 1.2 (330) 94.5 (312) 80.1 (7704) 4.30 2.67–6.94 <0.001* Foot/toe complaints 0.2 (62) 75.8 (47) 47.2 (4164) 3.50 1.96–6.27 <0.001* Arm complaints 0.2 (51) 78.4 (40) 52.3 (2074) 3.32 1.67–6.49 <0.001* Feeling depressed 0.2 (52) 78.8 (41) 58.8 (1196) 2.61 1.33–5.10 0.004* Knee complaints 0.2 (55) 72.7 (40) 50.7 (4071) 2.60 1.43–4.71 0.001* Leg/thigh complaints 0.2 (54) 70.4 (38) 53.4 (3869) 2.07 1.15–3.73 0.013* Feeling anxious/nervous/tense 0.2 (55) 87.3 (48) 77.4 (2555) 2.00 0.90–4.45 0.081 Relation problem partners 0.3 (81) 97.5 (79) 97.2 (840) 1.13 0.26–4.86 0.871 Overweight (BMI < 30) 0.2 (56) 0 (0) 2.7 (15) 1.10 1.08–1.13 0.212 Referral to secondary care Hearing complaints 0.2 (69) 46.4 (64) 13.9 (2026) 5.34 3.81–7.49 <0.001* Local swelling/papule/lump/mass 0.4 (99) 43.4 (86) 28 (7588) 1.98 1.49–2.63 <0.001* Visual complaints, other 0.4 (105) 66.7 (70) 54.8 (1018) 1.65 1.09–2.50 0.017* Nevus/mole 0.3 (71) 0 (0) 1.4 (72) 1.03 1.02–1.03 0.153 AIDS, acquired immune deficiency syndrome; BMI, body mass index; RFE, reason for encounter aOdds ratio, the odds of having a symptom diagnoses if presenting with a symptom and a request compared to the odds of having a symptom diagnosis without a request for intervention. bConfidence interval, determined by using Taylor series. cExpected count less than 5, Fisher’s exact test was used. *P value below 0.05, according to chi-square tests. View Large Discussion This is the first study analysing changes in patients’ requests for diagnostic and therapeutic interventions and changes in GPs’ compliance with these requests over the last three decades. It provides insight into patients’ behaviour and its contribution to the doctor–patient encounter. We found that almost all patients’ requests for interventions increased over the last 30 years. This suggests that patients are more self-empowered nowadays. Patients can search for medical information on the Internet and get informed by health programmes on television. The highest increase was found for urine test requests, which might be associated with dipstick testing that became commonplace in general practice. We found only one decrease in requests over time: patients’ request for referral to another primary care provider decreased in the last 20 years. Explanations for this might be that patients nowadays do not need a referral letter anymore to visit the physiotherapist and consequently patients can make an appointment with the physiotherapist without interference of the GP. Another explanation for this decrease could be the introduction of patient’s own risk in health insurance (the amount you have to pay yourself before the insurance company covers the medical costs) since 2008. This own risk is applicable to all primary and secondary care, except GP care. When patients have to pay for physiotherapist care, they probably wait longer to see whether complaints will disappear by themselves. GPs’ compliance with all investigated requests increased significantly over the past 30 years. Maybe patients nowadays more frequently ask for interventions that are medically indicated according to the GP, while previously they more frequently asked for interventions that are not indicated according to the GP. Another explanation might be the increased focus on shared decision making between patient and doctor nowadays. The total number of each intervention performed by GPs increased over time, except for medication prescription and referral to another primary care provider. Nowadays, more medication is available over the counter, so no prescription is needed. Furthermore, an increasing number of GP guideline might increase GPs’ watchful waiting, instead of directly prescribing medication. The increase in the total number of each intervention could hypothetically be explained by the aging population; however, this is not confirmed by our patient characteristics. Another explanation might be that doctors nowadays are possibly willing to take less risks and thereby perform more interventions. Another possible reason for this increase could be explained by following the guidelines for diabetes and cardiovascular risk factors where more interventions are needed in the first encounter. We found that patients asking for an intervention are more likely to be finally diagnosed with a symptom rather than a disease, while patients presenting with a symptom without asking for an intervention are more likely to be diagnosed with a disease. Possibly, patients asking for an intervention are more worried about their symptoms, have searched more extensively for information on the Internet or heard in their surroundings that others with certain symptoms got a specific intervention. This may lead to a request for intervention when they present to their GP. GPs are compliant with most of these requests. Given the fact that these patients are more likely to be finally diagnosed with a symptom (the GP could not finally diagnose a clear disease), it is expected that most medical investigations performed because of patients’ request will finally result in no abnormalities. In contrary, patients who present with a request for urine test are more often diagnosed with cystitis compared with the group without a request. This may be due to the fact that a lot of patients with cystitis recognize their symptoms from a previous cystitis and therefore ask directly for a urine test. Strengths and limitations A strength of this study is the large number of patients and encounters included. A recent study showed that the population in our database is representative for other countries (12). A limitation is that the data in the first 10 years of our study are registered by many GPs who only registered data for a short period of time. Data in these first 10 years are therefore less reliable. Another limitation is that we could not establish whether or not interventions were appropriate, beneficial or harmful. GPs did not register whether or not an intervention was medically indicated when the patient was asking for it. A last limitation is that we did not adjust for confounding factors (e.g. the introduction of patient’s own risk), which could have biased the results. Comparison with existing literature In our study, the percentage of GPs’ compliance with requests is higher (87%, range: 69%–100%) than what Soler and Okkes (17) found (56%, range: 45%–79%). The number of interventions originating from a request is slightly lower (11%, range: 3%–45%) compared with that of Soler and Okkes [15%, range: 6%–26% (17)]. A possible explanation for these differences might be that Soler and Okkes, perhaps, included other types of encounters. In our study, we included only first encounters of an episode of care. We excluded telephone consultations, repeat prescriptions and administrative records. Implications for research and practice This study shows the clinical relevance of the RFE in the doctor–patient encounter. Being aware of the RFE will lead to important information about patient’s needs, worries, expectations and even results of medical investigations. The GP should use this information to explore possible underlying concern, anxiety or ignorance and to explain whether or not to be compliant with patient’s request. To be aware of the predictive value of a request leading to a diagnosis could be useful to decide together with the patient to perform or not to perform a certain test: when a patient asks for an intervention, the GP can decide to discuss the results of this study (i.e. it is expected that most medical investigations performed because of patients’ request will finally result in no abnormality), especially when the GP thinks the request is not necessary. More research in this area is needed for supporting these findings to implicate in daily practice. For example, if the GP is compliant with a request, was it because it was medically needed or just to reassure the patient because it was requested? Is it possible to prevent inappropriate testing and waste of resources leading to better clinical practice? Supplementary Material Supplementary data are available at Family Practice online. Declaration Funding: none. Ethical approval: not necessary, as we used an anonymised database. Conflict of interest: none. Acknowledgement This study would not have been possible without the participation of the Transition Project doctors. References 1. olde Hartman TC , van Ravesteijn H , Lucassen P , et al. Why the ‘reason for encounter’ should be incorporated in the analysis of outcome of care . Br J Gen Pract 2011 ; 61 : e839 – 41 . Google Scholar PubMed 2. Hofmans-Okkes IM , Lamberts H . The International Classification of Primary Care (ICPC): new applications in research and computer-based patient records in family practice . Fam Pract 1996 ; 13 : 294 – 302 . Google Scholar CrossRef Search ADS PubMed 3. Kravitz RL , Epstein RM , Feldman MD , et al. Influence of patients’ requests for direct-to-consumer advertised antidepressants: a randomized controlled trial . JAMA 2005 ; 293 : 1995 – 2002 . Google Scholar CrossRef Search ADS PubMed 4. Hyde J , Calnan M , Prior L , et al. A qualitative study exploring how GPs decide to prescribe antidepressants . Br J Gen Pract 2005 ; 55 : 755 – 62 . Google Scholar PubMed 5. Cohen O , Kahan E , Zalewski S , Kitai E . Medical investigations requested by patients: how do primary care physicians react ? Fam Med 1999 ; 31 : 426 – 31 . Google Scholar PubMed 6. van Boven K , Uijen A , Wiel N , et al. Clinical relevance of alarm symptoms as reason for encounter for diagnosing cancer in primary care . J Am Board Fam Med November-December 2017; 30(6): 806–812 . 7. van Boxtel-Wilms SJ , van Boven K , Bor JH , et al. The value of reasons for encounter in early detection of colorectal cancer . Eur J Gen Pract 2016; 22 : 1 – 5 . 8. FaMe-net . www.transhis.nl. 9. Uijen A , Bor H , Boven K . FaMe-Net: twee oude registratienetwerken in een nieuw jasje . Tijdschrift voor gezondheidswetenschappen 2015 ; 93 : 286 – 7 . Google Scholar CrossRef Search ADS 10. Van Weel C . The continuous morbidity registration Nijmegen: background and history of a Dutch general practice database . Eur J Gen Pract 2008 ; 14 ( suppl 1 ): 5 – 12 . Google Scholar CrossRef Search ADS PubMed 11. Okkes I , Oskam S , van Boven K , Lamberts H . Episodes of care in family practice . Epidemiological data based on the routine use of the International Classification of Primary Care (ICPC) in the Transition Project of the Academic Medical Center/University of Amsterdam . In: Okkes IM , Oskam SK , Lamberts H (eds). ICPC in the Amsterdam Transition Project Amsterdam (cd-rom), 1995–2003 . Amsterdam: Academic Medical Center/University of Amsterdam, Department of Family Medicine, 2005. 12. Soler JK , Okkes I , Oskam S , et al. ; Transition Project . An international comparative family medicine study of the Transition Project data from the Netherlands, Malta and Serbia. Is family medicine an international discipline? Comparing incidence and prevalence rates of reasons for encounter and diagnostic titles of episodes of care across populations . Fam Pract 2012 ; 29 : 283 – 98 . Google Scholar CrossRef Search ADS PubMed 13. Soler JK , Okkes I , Wood M , Lamberts H . The coming of age of ICPC: celebrating the 21st birthday of the International Classification of Primary Care . Fam Pract 2008 ; 25 : 312 – 7 . Google Scholar CrossRef Search ADS PubMed 14. Lamberts H , Okkes I. ICPC-2, International Classification of Primary Care . Oxford: Oxford University Press, 1998 . 15. Hofmans-Okkes I , Lamberts H . Longitudinal research in general practice. The importance of including both patients’ and physicians’ perspectives on medical events . Scand J Prim Health Care Suppl 1993 ; 2 : 42 – 8 . Google Scholar CrossRef Search ADS PubMed 16. Lamberts H , Hofmans-Okkes I . Episode of care: a core concept in family practice . J Fam Pract 1996 ; 42 : 161 – 7 . Google Scholar PubMed 17. Soler JK , Okkes I . Reasons for encounter and symptom diagnoses: a superior description of patients’ problems in contrast to medically unexplained symptoms (MUS) . Fam Pract 2012 ; 29 : 272 – 82 . Google Scholar CrossRef Search ADS PubMed 18. van Boven K , Lucassen P , van Ravesteijn H , et al. Do unexplained symptoms predict anxiety or depression? Ten-year data from a practice-based research network . Br J Gen Pract Jun 2011; 61(587): e316 – 25 . © The Author(s) 2018. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)

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Family PracticeOxford University Press

Published: Apr 26, 2018

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