The Unexpected in Primary Care: A Multicenter Study on the Emergence of Unvoiced Patient Agenda

Michael Peltenburg; Joachim E. Fischer; Ottomar Bahrs; Sandra van Dulmen; Atie van den Brink-Muinen

doi:10.1370/afm.241

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Table 1.

Percentage of Patients With Preconsultation and Postconsultation Questionnaire Difference Scores, Emerging Agendas, and Met and Unmet Expectations

	Difference Score*
Items	2 to 3	−1 to 1	−3 to −2
Biomedical factor
Explanation of symptoms	14.9	76.5	8.6
Confirmation of diagnosis	21.1	70.7	8.2
Nature of problem	20.2	74.4	5.3
Physical examination	19.3	70.9	9.8
Explanation of test results	10.0	72.4	17.7
Explanation of prognosis	14.2	68.7	17.0
Explanation of severity	13.6	68.4	18.0
Psychosocial factor
Help for anxiousness	23.7	70.6	5.7
Help for emotional problems	14.8	81.4	3.9
Explanation of emotional problems	9.8	84.0	6.3
Support for difficult times	18.0	78.1	3.9

	Emerging Agenda^†	Expectation Met	Unmet Expectation
* Difference scores were obtained by subtracting the preconsultation item score from the postconsultation item score. In this way, positive difference scores indicate that the patient reports care exceeding expectations. Patients reported significantly higher levels of unmet expectations for explanation of test results, prognosis, and severity of their problem than for any other item (P <.001).
† For emerging agenda, 10.4% of the patients had only biomedical emerging agenda, 11.7% of the patients had only psychosocial emerging agenda, and 4.1% of the patients had both.
Aggregated categorical score
Biomedical factor	14.5	74.2	10.3
Psychosocial factor	15.8	70.6	13.6

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Table 2.

Variables Associated With Emerging Agendas

Explanatory Variable	Explained Variance % (PartialR²)	Direction of Association*	Adjusted Odds Ratio (CI)^†
* Direction of association: the – sign denotes a negative association, the + sign denotes a positive association. For region and for the practice dummy variable, associations varied.
† Adjusted odds-ratio (OR): To illustrate the magnitude of the effects, the adjusted odds-ratio for emerging biomedical or psychosocial agenda are computed for a patient scoring in the highest quartile on the respective scale compared with a patient scoring in the lowest quartile. Odds ratios are adjusted for all other variables that were significant in the multivariable analysis of the continuous outcome measure. The model predicting an emerging psychosocial agenda performed well (area under the receiver operating characteristic curve was α = 0.76) and the Hosmer-Lemeshow statistics showed an excellent fit with a P = .77. The confidence interval (CI) is provided in parenthesis. Odds ratios for region and practice dummy variables are not shown (NA).
‡ Comparison of the third quartile with the lowest quartile. Patients with very high psychosocial expectations were less likely to report emerging psychosocial agenda (adjusted OR = 0.66, 95% CI, 0.45 – 0.97), suggesting possible ceiling effects of the instrument.
Biomedical factor
Full model	42.3
Patient prior biomedical expectation	27.4	−	0.02 (0.01–0.04)
Patient prior psychosocial expectations	.3	−	1.8 (1.24–2.7)
Biomedical discourse content	1.2	+	2.2 (1.5–3.1)
Physician perceived psychosocial reason for encounter	0.6	−	0.8 (0.6–1.2)
Region	1.0	Variable	NA
Practice dummy variable nested within region	7.9	Highly variable	NA
Psychosocial factor
Full model	29.3
Patient prior psychosocial expectations	13.2	+ / −^‡	3.3 (2.3–4.7)^‡
Age	.1	+	2.0 (1.3–3.1)
Physical fitness	.2	+	1.3 (0.9–1.9)
Patient education	.1	−	0.7 (0.5–1.1)
Bothered by emotional problems	1.6	+	1.9 (1.3–2.8)
Patient perceived psychosocial reason for consultation	.2	+	1.1 (0.7–1.8)
Physician perceives underlying psychosocial problem	.8	+	2.0 (1.4–2.9)
Affective or psychosocial discourse	.8	+	1.5 (1.0–2.1)
Proportion of consultation time physician is listening	.2	+	1.1 (0.8–1.6)
Region	.9	Variable	NA
Practice dummy variable nested within region	7.4	Highly variable	NA

Additional Files

Tables

Supplemental Appendix and Table

Supplemental Table: Patient and Physician Characteristics of Study Sample; Supplemental Appendix: The 7 High-Loading Items on the Biomedical-Informational Scale and the 4 High-Loading Items on the Emotional-Psychosocial Scale

Files in this Data Supplement:

Supplemental data: Table - PDF file, 2 pages, 271 KB
Supplemental data: Appendix - PDF file, 1 page, 143 KB
The Article in Brief

Unexpected topics often arise during a visit to a primary care doctor. In a study of 2,243 European patients, topics that neither the patient nor the doctor expected to address came up in nearly 1 of every 7 visits. Doctors can help develop the agenda for the medical visit by encouraging patients to raise issues they may be hesitant to discuss.