Improving primary care for patients with chronic illness

The chronic care model is a guide to higher-quality chronic illness management within primary care. The model predicts that improvement in its 6 interrelated components-self-management support, clinical information systems, delivery system redesign, decision support, health care organization, and community resources-can produce system reform in which informed, activated patients interact with prepared, proactive practice teams. Case studies are provided describing how components of the chronic care model have been implemented in the primary care practices of 4 health care organizations.

Prostate cancer detection in a clinical urological practice by ultrasonography, digital rectal examination and prostate specific antigen

The prostate cancer detection rate from screening by digital rectal examination and tactilely guided prostate biopsy is approximately 1.7%. Among 1,807 men a detection rate of 14.6% was achieved in a clinical urological practice by physician-conducted prostate ultrasonography, digital rectal examination and determination of serum prostate specific antigen. Results are presented in 5-year increments as well as for the group as a whole. The possible benefit to be derived from an improved detection rate is undetermined. Recommendations are made regarding the clinical use of these diagnostic modalities.

Mental disorders and disability among patients in a primary care group practice

OBJECTIVE

This article examines social and occupational disability associated with several DSM-IV mental disorders in a group of adult primary care outpatients.

METHOD

The subjects were 1,001 primary care patients (aged 18-70 years) in a large health maintenance organization. Data on each patient's sociodemographic characteristics and functional disability, including scores on the Sheehan Disability Scale, were collected at the time of a medical visit. A structured diagnostic interview for current DSM-IV disorders was then completed by a mental health professional over the telephone within 4 days of the visit.

RESULTS

The most prevalent disorders were phobias (7.7%), major depressive disorder (7.3%), alcohol use disorders (5.2%), generalized anxiety disorder (3.7%), and panic disorder (3.0%). A total of 8.3% of the patients met the criteria for more than one mental disorder. The proportion of patients with co-occurring mental disorders varied by index disorder from 50.0% (alcohol use disorder) to 89.2% (generalized anxiety disorder). Compared with patients who had a single mental disorder, patients with co-occurring disorders reported significantly more disability in social and occupational functioning. After adjustment for other mental disorders and demographic and general health factors, compared with patients with no mental disorder, only patients with major depressive disorder, bipolar disorder, phobias, and substance use disorders had significantly increased disability, as measured by the Sheehan Disability Scale.

CONCLUSIONS

Primary care patients with more than one mental disorder are common and highly disabled. Individual mental disorders have distinct patterns of psychiatric comorbidity and disability.

Use of medicines in general practice

The prescriptions issued by general practitioners to a population of about 40 000 people were studied. During one year 53-8% of all males and 65-7% of all females had at least one drug dispensed. The proportion receiving medicines increased with age and was higher among females at all ages. Psychotropic drugs were prescribed more often than any other group and accounted for almost one-fifth of all prescriptions. Altogether 9-7% of the males in the population and 21-0% of the females received at least one psychotropic drug during the year. Among women aged 45-59 33-0% received a psychotropic drug, and 11-2% were given an antidepressant. Althoug antimicrobial drugs were prescribed less often than psychotropic drugs, they were given to more people.

Measurement of work satisfaction among health professionals

This paper describes a three-year research project that investigates the concept of occupational satisfaction of health professionals and suggests a method of measuring their level of occupational satisfaction. Additionally, the research examines factors defining occupational satisfaction important to health professionals. This process involves the development of a scale that measures the relative importance of various components of satisfaction, attitudes toward these components, and a weighted Index of Work Satisfaction. The methodology utilized in the development of this scale in an institutional setting with a sample of nurses is described, along with the transfer of this scale to three categories of health professionals involved in an outpatient setting. Responses from the physicians, nurses, and support staff in the ambulatory setting and responses from the hospital nurses indicate that the scale does measure occupational satisfaction of health professionals both in institutional and noninstitutional settings. Finally, statistical analysis of the original scale is reported and a revised scale is suggested for wider use.

Physician job satisfaction: developing a model using qualitative data. SGIM Career Satisfaction Study Group

The purpose of this study was to develop a current and comprehensive model of physician job satisfaction. Information was gathered by (1) analysis of open-ended responses from a large group practice physician survey in 1988, and (2) analysis of focus group data of diverse physician subgroups from 1995. Participants were 302 physicians from large-group practices and 26 participants in six focus groups of HMO, women, minority, and inner-city physicians. Data were used to develop a comprehensive model of physician job satisfaction. The large group practice survey data supported the key importance of day-to-day practice environment and relationships with patients and physician peers. Future concerns focused on the effect of managed care on the physician-patient relationship and the ability of physicians to provide quality care. Focus groups provided contemporary data on physician job satisfaction, reinforcing the centrality of relationships as well as special issues for diverse physician subgroups of practicing physicians. New variables that relate to physician job satisfaction have emerged from economic and organizational changes in medicine and from increasing heterogeneity of physicians with respect to gender, ethnicity, and type of practice. A more comprehensive model of physician job satisfaction may enable individual physicians and health care organizations to better understand and improve physician work life.

Safety of telephone triage in general practitioner cooperatives: do triage nurses correctly estimate urgency?

BACKGROUND

In recent years, there has been a growth in the use of triage nurses to decrease general practitioner (GP) workloads and increase the efficiency of telephone triage. The actual safety of decisions made by triage nurses has not yet been assessed.

OBJECTIVES

To investigate whether triage nurses accurately estimate the urgency level of health complaints when using the national telephone guidelines, and to examine the relationship between the performance of triage nurses and their education and training.

METHOD

A cross-sectional, multicentre, observational study employing five mystery (simulated) patients who telephoned triage nurses in four GP cooperatives. The mystery patients played standardised roles. Each role had one of four urgency levels as determined by experts. The triage nurses called were asked to estimate the level of urgency after the contact. This level of urgency was compared with a gold standard.

RESULTS

Triage nurses estimated the level of urgency of 69% of the 352 contacts correctly and underestimated the level of urgency of 19% of the contacts. The sensitivity and specificity of the urgency estimates provided by the triage nurses were found to be 0.76 and 0.95, respectively. The positive and negative predictive values of the urgency estimates were 0.83 and 0.93, respectively. A significant correlation was found between correct estimation of urgency and specific training on the use of the guidelines. The educational background (primary or secondary care) of the nurses had no significant relationship with the rate of underestimation.

CONCLUSION

Telephone triage by triage nurses is efficient but possibly not safe, with potentially severe consequences for the patient. An educational programme for triage nurses is recommended. Also, a direct second safety check of all cases by a specially trained GP telephone doctor is advisable.

Which Physicians And Practices Are Using Electronic Medical Records?

Greater use of electronic medical records (EMRs) has the potential to improve the quality of medical care and has become a goal of the U.S. administration. According to the National Ambulatory Medical Care Survey, only an average of 17.6 percent of physicians reported use of EMRs in their office-based practices. The adoption rate did not increase from 2001 through 2003. Practices with more physicians and those owned by health maintenance organizations (HMOs) were significantly more likely to use this technology, but use varied little by the characteristics of individual physicians, the practice's scope of services, or the practice's sources of revenue.

Perceptions of diagnostic terminology and cytopathologic reporting of fine-needle aspiration biopsies of thyroid nodules: a survey of clinicians and pathologists

INTRODUCTION

Guidelines on thyroid fine-needle aspiration biopsy (FNABs) reporting calls for unambiguous diagnostic terminology in order to maximize treatment. This study evaluates how pathologists follow the guidelines and clinicians understand the diagnostic categories in terms of patient care.

DESIGN

Survey 1 asked pathologists who perform/interpret FNABs which of "atypical," "indeterminate," "suspicious," and "nondiagnostic" they routinely use. Survey 2 asked clinicians who treat thyroid nodules to correlate these categories to the options of "negative FNAB/follow-up," "repeat FNAB," and "proceed to surgery." The anonymous, voluntary results were entered into a database and analyzed.

MAIN OUTCOME

Pathologists' and clinicians' response rates were 70% and 35%, respectively. Survey 1: 27% of pathologists used three, 27% used one, and 44% used two categories. Survey 2: 98% clinicians would repeat the FNAB with a "nondiagnostic" and 96% opted for surgery with a "suspicious" diagnosis. "Indeterminate" prompted 58% to repeat the FNAB and 32% to send the patient to surgery. "Atypical" would lead 37% to repeat the FNAB and 52% to send the patient to surgery.

CONCLUSIONS

Pathologists actively use the terminology "suspicious," "indeterminate," or "atypical," which cause confusion in some clinicians. These results support the need for a more standardized terminology for FNAB reporting and education of the clinicians on that terminology.

Patient difficulty using tablet computers to screen in primary care

BACKGROUND

Patient-administered computerized questionnaires represent a novel tool to assist primary care physicians in the delivery of preventive health care.

OBJECTIVE

The aim of this study was to assess patient-reported ease of use with a self-administered tablet computer-based questionnaire in routine clinical care.

DESIGN

All patients seen in a university-based primary care practice were asked to provide routine screening information using a touch-screen tablet computer-based questionnaire. Patients reported difficulty using the tablet computer after completion of their first questionnaire.

PATIENTS

Ten thousand nine hundred ninety-nine patients completed the questionnaire between January 2004 and January 2006.

MEASUREMENTS

We calculated rates of reporting difficulty (no difficulty, some difficulty, or a lot of difficulty) using the tablet computers based on patient age, sex, race, educational attainment, marital status, and number of comorbid medical conditions. We constructed multivariable ordered logistic models to identify predictors of increased self-reported difficulty using the computer.

RESULTS

The majority of patients (84%) reported no difficulty using the tablet computers to complete the questionnaire, with only 3% reporting a lot of difficulty. Significant predictors of reporting more difficulty included increasing age [odds ratio (OR) 1.05, 95% confidence interval (CI) 1.05-1.05)]; Asian race (OR 2.3, 95% CI 1.8-2.9); African American race (OR 1.4, 95% CI 1.2-1.6); less than a high school education (OR 3.0, 95% CI 2.6-3.4); and the presence of comorbid medical conditions (1-2: OR 1.3, 95% CI 1.2-1.5; > or =3: OR 1.7 95% CI 1.5-2.1).

CONCLUSIONS

The majority of primary care patients reported no difficulty using a self-administered tablet computer-based questionnaire. While computerized questionnaires present opportunities to collect routine screening information from patients, attention must be paid to vulnerable groups.

Clinical predictors of functioning in persons with acquired immunodeficiency syndrome

To help clinicians better assess and treat functional disabilities in persons with acquired immunodeficiency syndrome (AIDS), the authors estimate empirical relations among biologic and physiologic variables, symptoms, and physical functioning in persons with AIDS. The sample of 305 persons with AIDS for this cross-sectional analysis came from three sites in Boston, Massachusetts: a hospital-based group practice, a human immunodeficiency virus clinic at a city hospital, and a staff-model health maintenance organization. Physical functioning, 10 AIDS-specific symptoms, and mental health were assessed by interview. Clinical diagnoses, comorbidities, health habits such as smoking, laboratory results, and selected medication use were assessed by chart review. Significant predictors of physical functioning P < 0.01, R2 = .58) in a multivariable regression model included energy/fatigue, neurologic symptoms, fever symptoms, a lower hemoglobin level, and current non-pneumonia bacterial infection. Ninety-six percent of the explained variance in physical functioning was accounted for by three symptom complexes: energy/fatigue, neurologic symptoms, and fever symptoms. Significant predictors of energy/fatigue in multivariable models included poorer mental health, lower white blood cell count, longer time since diagnosis, and weight loss (P < 0.01, R2 =.36). Significant predictors of neurologic symptoms included poorer mental health, weight loss, and no zidovudine use (P < 0.001, R2 = .30). Predictors of fever symptoms included poorer mental health, no zidovudine use, weight loss, and history of asthma or chronic obstructive pulmonary disease (P < 0.05, R2 = .25). In conclusion, symptom reports were strong predictors of physical functioning. Poorer mental health and weight loss were correlated consistently with worse symptoms, and not using zidovudine was correlated with worse neurologic and fever symptoms. These variables, and the others the authors identified, may represent mutable determinants of physical functioning in persons with AIDS, and potential targets for specific clinical interventions.

Mental health care in the community: an evaluative study

A study was designed to assess the therapeutic value of attaching a social worker to a metropolitan group practice in the management of chronic neurotic illness. The psychiatric and social status of a group of patients before treatment and after one year was compared with the status of a control group treated more conventionally over the same period. The results indicate that the experimental service conferred some benefit on the patient population.

Individual and institutional variables which may serve as indicators of quality of medical care

This article is a critical review of empiric studies, in the medical care literature of the past two decades, that investigated associations between characteristics of physicians and medical care institutions and some measure of the quality of medical care given by them. The intention is to identify those characteristics of physicians and medical care institutions which can be considered the best indicators of the quality of performance to be expected, given the present state of knowledge. The analysis discusses 18 such characteristics but derives a list of 14 which appear to be the best choice of indicators on which further research might focus. It would be possible to design a survey instrument based on these characteristics, which, if upheld by empiric testing, could serve as a crude assessment tool for third parties needing to make quality comparisons between medical care institutions.

Parenting stress and the utilization of pediatric services

Parents' level of stress as measured by the Parenting Stress Index is examined in relation to the utilization of pediatric medical services for children between the ages of 1 and 48 months. The six categories of medical services considered were: Well Visits, Sick Visits, Infections, Diarrhea and Vomiting, Traumatic Injuries, and Other Medical Services. For the first 18 months of age no significant mean difference between stress groups and medical utilization was found. Significant correlations and mean differences were found for the 19- to 24- and the 25- to 48-month age groups in relation to the traumatic injury criterion. Moderate parenting stress is interpreted as potentially adaptive in relation to reducing traumatic injuries.

Diffusion of laparoscopic cholecystectomy among general surgeons in the United States

Introduced in 1989, laparoscopic cholecystectomy has rapidly become the treatment of choice for symptomatic gallstones. This study describes the diffusion of laparoscopic cholecystectomy among general surgeons; assesses the importance of various reasons for surgeons adopting the procedure; and examine the influence of surgeon, practice, and health care market characteristics on the timing of adoption. The data were obtained from a survey of a national sample of surgeons. Most surgeons (81%) adopted laparoscopic cholecystectomy by early 1992. More than three fourths of adopters identified the desire to keep up with the state-of-the-art and improved patient outcomes as very or extremely important reasons for adoption. Results of proportional hazards regression analysis indicate that individual surgeons' adoption behavior generally was consistent with expected utility maximization in an uncertain new technological environment. Of particular interest, fee-for-service payment and more competitive practice settings and markets were associated with earlier adoption. These findings suggest that the "technological imperative" and surgeons' perception of the relative clinical and financial advantages of laparoscopic cholecystectomy were important reasons for the rapid diffusion of laparoscopic cholecystectomy. Policies that accelerate current trends toward payment of physicians based on salary or capitation and promote the growth of multispecialty group practice could slow the diffusion of new physician-based product innovations in health care.

The orginization of medical practice and practice orientations among physicians in prepaid and nonprepaid primary care settings

Data are presented on office-based general practitioners and pediatricians working in varying practice settings. Fee-for-service physicians spend more time in direct patient care activities than those in prepaid practice, and devote more time to each patient. The data suggest that the patient load characteristic of general practice in prepaid groups encourages a more assembly line practice which is less responsive to patients than the pattern characteristic of fee-for-service practice. Prepaid physicians work during scheduled hours and may deal with increased load by processing patients more rapidly. Fee-for-service physicians tend to respond to increased demand by working longer hours. The responsiveness of primary care physicians to patient problems seems to reflect primarily their social orientations to medical practice and the time pressures they face. Varying practice settings result in different techniques of coping with the pressures of practice. Data are also presented on sociodemographic and professional characteristics of primary care physicians in varying settings, workload, use of diagnostic and laboratory procedures, social orientations to medical practice, satisfactions and dissatisfactions, and attitudes toward sociopolitical aspects of medical care. Suggestions are offered for improving the responsiveness of prepaid practice.

Salary equity among male and female internists in Pennsylvania

BACKGROUND

Women constitute an increasing proportion of physicians in the United States. Historically, inequities have existed between male and female physicians in professional advancement, but evidence has suggested that disparities in salary are resolving.

OBJECTIVE

To examine the current state of salary equity among male and female internists.

DESIGN

Population-based survey mailed to all Board-certified female internists and a matched group of male internists who had graduated from medical school 10 to 30 years ago and were currently practicing.

SETTING

Pennsylvania.

PARTICIPANTS

232 male and 213 female internists for whom data were complete.

MEASUREMENTS

Respondents answered questions about demographic characteristics, training, practice type and setting, status within the practice, family life, and salary.

RESULTS

Women were more likely to be involved in the least lucrative practice arrangements. They were more likely to be in low-paying specialties, to not be a partner in the practice, and to be salaried employees; they also spent fewer hours per week seeing patients. Even after adjustment for these differences, hourly earnings were significantly higher (14%) among men than among their female colleagues. Men's earnings significantly exceeded women's earnings among physicians with no academic affiliation, those in high-earning specialties, and those in general internal medicine.

CONCLUSIONS

Significant salary differentials exist between male and female internists overall and in various medical practice settings.

Unsaid but not forgotten: patients' unvoiced desires in office visits

OBJECTIVES

To examine patient, physician, and health care system characteristics associated with unvoiced desires for action, as well as the consequences of these unspoken requests.

PATIENTS AND METHODS

Patient surveys were administered before, immediately after, and 2 weeks after outpatient visits in the practices of 45 family practice, internal medicine, and cardiology physicians working in a multispecialty group practice or group model health maintenance organization. Data were collected at the index visit from 909 patients, of whom 97.6% were surveyed 2 weeks after the outpatient visit. Before the visit, patients rated their trust in the physician, health concerns, and health status. After the visit, patients reported on various types of unexpressed desires and rated their visit satisfaction. At follow-up, patients rated their satisfaction, health concerns, and health status, and also described their postvisit health care use. Evaluations of the visit were also obtained from physicians.

RESULTS

Approximately 9% of the patients had 1 or more unvoiced desire(s). Desires for referrals (16.5% of desiring patients) and physical therapy (8.2%) were least likely to be communicated. Patients with unexpressed desires tended to be young, undereducated, and unmarried and were less likely to trust their physician. Patients with unvoiced desires evaluated the physician and visit less positively; these encounters were evaluated by physicians as requiring more effort. Holding an unvoiced desire was associated with less symptom improvement, but did not affect postvisit health care use.

CONCLUSIONS

Patients' unvoiced needs affect patients' and physicians' visit evaluations and patients' subjective perceptions of improvement. Implications of these findings for clinical practice are examined.