Influence of Watchful Waiting on Satisfaction and Anxiety Among Patients Seeking Care for Unexplained Complaints

Marloes A. van Bokhoven; Hèlen Koch; Trudy van der Weijden; Richard P. T. M. Grol; Arnold D. Kester; Paula E. L. M. Rinkens; Patrick J. E. Bindels; Geert-Jan Dinant

doi:10.1370/afm.958

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Figure 1.
Randomization scheme, numbers of participants, and questionnaires used.

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Table 1.

Instruments and Variables

Instrument	Completed By	Variables
^a One form was completed for each individual type of complaint.
Primary care physician characteristics form	Primary care physicians	Demographic data
		Practice characteristics
		Continuing medical education
		Laboratory facilities available in practice
Complaint registration form^a	Primary care physicians	Symptoms
		Signs
		Working hypothesis
		Degree of lack of explanation
		Degree of suspicion of serious pathology
		Degree of insecurity of primary care physician
		Satisfaction of primary care physician with consultation
Patient characteristics form	Patients	Demographic data
		Type of health insurance
		Level of education
Patient questionnaire	Patients	Intensity of complaints
		Course of complaints
		Satisfaction with consultation
		Anxiety before and after consultation
		Satisfaction with primary care physician
Test results form	Laboratory	Blood test results

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Table 2.

Characteristics of Physicians (N = 91)

		Group
Characteristic	Total Sample (N=91)	Immediate Test Ordering (n=33)	Watchful Waiting (n=29)	Watchful Waiting+QI (n=29)
QI=quality improvement; CME=continuing medical education.
^a Out of 4 possible topics: unexplained complaints, physician-patient communication, time management, and diagnostic testing.
Age, mean (SD), years	45 (7.3)	47 (5.8)	44 (7.2)	45 (8.8)
Sex, No. (%) male	67 (74)	26 (79)	17 (59)	24 (83)
Experience as a primary care physician, mean (SD), years	13 (8.7)	14 (7.1)	11 (8.4)	14 (10.4)
Practice type, No. (%) solo	34 (37)	9 (27)	15 (52)	10 (34)
Practice region, No. (%) in western region	44 (48)	19 (58)	11 (38)	14 (48)
Practice location, No. (%)
Urban	45 (50)	15 (47)	15 (52)	15 (52)
Semirural	11 (12)	4 (13)	5 (17)	2 (7)
Rural	34 (38)	13 (41)	9 (31)	12 (41)
Number of topics done during CME, mean (SD)^a	1.9 (1.6)	1.9 (1.6)	2.3 (1.1)	1.5 (1.6)
Number of available laboratory tests in own practice, mean (SD)	2.4 (1.1)	2.4 (1.2)	1.9 (1.0)	2.6 (0.9)

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Table 3.

Characteristics of Patients (N = 498)

		Group
Characteristic	Total Sample (N=498)	Immediate Test Ordering (n=229)	Watchful Waiting (n=95)	Watchful Waiting+QI (n=174)
QI=quality improvement.
Note: Percentages may not total to !00% because of rounding and missing data for a few patients.
^a Vs compulsory.
Age, mean (SD), years	43 (16.2)	42 (15.5)	45 (15.2)	45 (17.5)
Sex, No. (%) male	140 (28)	67 (29)	18 (19)	55 (32)
Type of health insurance, No. (%) with private^a	164 (34)	80 (35)	37 (39)	47 (27)
Highest level of education completed, No. (%)
None	4 (1)	2 (1)	1 (1)	1 (1)
Primary	46 (10)	20 (9)	5 (5)	21 (12)
Secondary	323 (67)	146 (64)	65 (68)	112 (64)
Higher	106 (22)	55 (24)	21 (22)	30 (17)

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Table 4.

Patients’ Satisfaction With and Anxiety After the Consultation

		Group
Measure	Total Sample (N=498)	Immediate Test Ordering (n=229)	Watchful Waiting (n=95)	Watchful Waiting+QI (n=174)
QI=quality improvement.
^a On a scale of 0 to 10, where a higher score indicates greater satisfaction or greater anxiety.
Satisfaction, mean (SD) score^a	7.3 (2.0)	7.4 (2.1)	7.4 (1.9)	7.1 (2.1)
Anxiety, mean (SD) score^a	3.1 (2.5)	3.1 (2.5)	3.4 (2.7)	2.8 (2.4)

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Table 5.

Odds of Patient Satisfaction With the Consultation in the Multivariate, Multilevel Logistic Regression Analysis

Variable	Adjusted Odds Ratio (95% CI)
CI=confidence interval; ref = reference group; QI = quality improvement.
Notes: Detailed definitions for each category are given in the supplemental tables. Group was retained in the model using 2 dummy variables. The intra-cluster correlation coefficient was 2.37 e⁻⁷.
Group
Immediate test ordering	1.00 (ref)
Watchful waiting	0.84 (0.39–1.82)
Watchful waiting + QI	0.91 (0.48–1.72)
Patient was generally satisfied with physician
Yes	14.39 (7.63–27.14)
No	1.00 (ref)
Patient felt taken seriously
Yes	7.56 (1.88–30.36)
No or unknown	1.00 (ref)
Physician discussed laboratory testing with patient, according to patient
Yes	2.28 (1.28–4.07)
No or unknown	1.00 (ref)
Patient knew seriousness of complaints after the consultation, according to patient
Yes	2.07 (1.18–3.63)
No	1.00 (ref)
Age of physician
≤ 46 years	0.47 (0.26–0.84)
>46 years	1.00 (ref)
Physician considered complaints bearable
Yes	0.30 (0.11–0.78)
No	1.00 (ref)

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Table 6.

Odds of Patient Anxiety After the Consultation in the Multivariate, Multilevel Logistic Regression Analysis

Variable	Adjusted Odds Ratio (95% CI)
CI=confidence interval; ref = reference group; QI = quality improvement.
Notes: Detailed definitions for each category are given in the supplemental tables. Group was retained in the model using 2 dummy variables. The intra-cluster correlation coefficient was 2.53 e⁻⁷.
Group
Immediate test ordering	1.00 (ref)
Watchful waiting	2.25 (1.09–4.60)
Watchful waiting + QI	1.12 (0.64–1.97)
Patient had anxiety before the consultation
Yes	6.83 (4.15–11.25)
No	1.00 (ref)
Patient expected referral to a specialist
Yes	2.64 (1.52–4.57)
No or did not care	1.00 (ref)
Physician felt certain that there was no cause for alarm
Yes	2.37 (1.02–5.51)
No	1.00 (ref)
Physician took a special interest in psychiatry, psychosomatics, or unexplained complaints
Yes	2.21 (1.13–4.31)
No	1.00 (ref)
Physician performed physical examination
Yes	2.03 (1.11–3.72)
No	1.00 (ref)
Patient expected blood tests to be ordered
Yes	1.84 (1.07–3.20)
No or unknown	1.00 (ref)
Patient considered complaints bearable
Yes	0.56 (0.32–0.97)
No	1.00 (ref)
Patient was satisfied with the consultation
Yes	0.53 (0.32–0.88)
No	1.00 (ref)
Patient knew seriousness of complaints after the consultation, according to patient
Yes	0.45 (0.25–0.79)
No	1.00 (ref)

Additional Files

Figures
Tables

Supplemental Tables

Supplemental Table 1. Results of Bivariate Analysis of Patient Satisfaction With the Consultation; Supplemental Table 2. Results of Bivariate Analysis of Patient Anxiety After the Consultation

Files in this Data Supplement:

Supplemental data: Tables 1-2 - PDF file, 4 pages, 113 KB
The Article in Brief

Influence of Watchful Waiting on Satisfaction and Anxiety Among Patients Seeking Care for Unexplained Complaints

Marloes A. van Bokhoven and colleagues

Background Blood tests are often ordered for patients with unexplained symptoms. Although such tests may not provide a diagnosis, many doctors feel they will reassure patients. The purpose of this study is to determine whether immediate ordering of tests, compared with watchful waiting (in which the doctor observes the patient's condition but doesn't take immediate action), influences patient satisfaction with the doctor visit and anxiety after the visit.

What This Study Found Among patients with unexplained symptoms, ordering blood tests does not increase satisfaction with the visit or lower their anxiety. Instead, patients value specific aspects of physician-patient communication, such as feeling that they are taken seriously, discussing testing with the doctor, and understanding the seriousness of their complaints.

Implications

Primary care doctors may overestimate the importance of additional testing in patients with unexplained complaints and underestimate how much they themselves can contribute to their patients� well-being by discussing their worries.