James A. Bobula

Working Conditions in Primary Care: Physician Reactions and Care Quality

BACKGROUND Adverse primary care work conditions could lead to a reduction in the primary care workforce and lower-quality patient care. OBJECTIVE To assess the relationship among adverse primary care work conditions, adverse physician reactions (stress, burnout, and intent to leave), and patient care. DESIGN Cross-sectional analysis. SETTING 119 ambulatory clinics in New York, New York, and in the upper Midwest. PARTICIPANTS 422 family practitioners and general internists and 1795 of their adult patients with diabetes, hypertension, or heart failure. MEASUREMENTS Physician perception of clinic workflow (time pressure and pace), work control, and organizational culture (assessed survey); physician satisfaction, stress, burnout, and intent to leave practice (assessed by survey); and health care quality and errors (assessed by chart audits). RESULTS More than one half of the physicians (53.1%) reported time pressure during office visits, 48.1% said their work pace was chaotic, 78.4% noted low control over their work, and 26.5% reported burnout. Adverse workflow (time pressure and chaotic environments), low work control, and unfavorable organizational culture were strongly associated with low physician satisfaction, high stress, burnout, and intent to leave. Some work conditions were associated with lower quality and more errors, but findings were inconsistent across work conditions and diagnoses. No association was found between adverse physician reactions, such as stress and burnout, and care quality or errors. LIMITATION The analyses were cross-sectional, the measures were self-reported, and the sample contained an average of 4 patients per physician. CONCLUSION Adverse work conditions are associated with adverse physician reactions, but no consistent associations were found between adverse work conditions and the quality of patient care, and no associations were seen between adverse physician reactions and the quality of patient care.

How Many Problems Do Family Physicians Manage at Each Encounter? A WReN Study

PURPOSE The number of problems managed concurrently by family physicians during patient encounters has not been fully explored despite the implications for quality assessment, guideline implementation, education, research, administration, and funding. Our study objective was to determine the number of problems physicians report managing at each visit and compare that with the number reflected in the chart and the bill. METHODS Twenty-nine members of the Wisconsin Research Network reported on encounters with 572 patients using a physician problem log. The patient chart notes and the diagnoses submitted for billing from the encounters were compared with the information in these logs. RESULTS The physicians reported managing an average of 3.05 problems per encounter and recorded 2.82 in the chart and 1.97 on the bill. For all patients, 37% of encounters addressed more than 3 problems, and 18% addressed more than 4. For patients older than 65 years, there was an average of 3.88 problems at each visit, and for diabetic patients there was an average of 4.60. There was evidence for the selective omission of mental health and substance problems from the diagnoses used for billing. CONCLUSIONS Family medicine involves the concurrent care of multiple problems, which billing data do not adequately reflect. Our findings suggest a mismatch between family medicine and current approaches to quality assessment, guideline implementation, education, research, administration, and funding. Activities in all these areas need to address the physician’s task of prioritizing and integrating care for multiple problems concurrently.

Separate and Unequal: Clinics Where Minority and Nonminority Patients Receive Primary Care

BACKGROUND Few studies have examined the influence of physician workplace conditions on health care disparities. We compared 96 primary care clinics in New York, New York, and in the upper Midwest serving various proportions of minority patients to determine differences in workplace organizational characteristics. METHODS Cross-sectional data are from surveys of 96 clinic managers, 388 primary care physicians, and 1701 of their adult patients with hypertension, diabetes mellitus, or congestive heart failure participating in the Minimizing Error, Maximizing Outcome (MEMO) study. Data from 27 clinics with at least 30% minority patients were contrasted with data from 69 clinics with less than 30% minority patients. RESULTS Compared with clinics serving less than 30% minority patients, clinics serving at least 30% minority patients have less access to medical supplies (2.7 vs 3.4, P < .001), referral specialists (3.0 vs 3.5, P < .005) on a scale of 1 (none) to 4 (great), and examination rooms per physician (2.2 vs 2.7, P =.002) . Their patients are more frequently depressed (22.8% vs 12.1%), are more often covered by Medicaid (30.2% vs 11.4%), and report lower health literacy (3.7 vs 4.4) on a scale of 1 (low) to 5 (high) (P < .001 for all). Physicians from clinics serving higher proportions of minority populations perceive their patients as frequently speaking little or no English (27.1% vs 3.4%, P =.004), having more chronic pain (24.1% vs 12.9%, P < .001) and substance abuse problems (15.1% vs 10.1%, P =.005), and being more medically complex (53.1% vs 39.9%) and psychosocially complex (44.9% vs 28.2%) (P < .001 for both). In regression analyses, clinics with at least 30% minority patients are more likely to have chaotic work environments (odds ratio, 4.0; P =.003) and to have fewer physicians reporting high work control (0.2; P =.003) or high job satisfaction (0.4; P =.01). CONCLUSION Clinics serving higher proportions of minority patients have more challenging workplace and organizational characteristics.

Enhancing survey data collection among youth and adults: Use of handheld and laptop computers

Tobacco use, alcohol and other drug use, early sexual behavior, dietary practices, physical inactivity, and activities that contribute to unintentional and intentional injuries are a significant threat to the health of young people. These behaviors have immediate and long-term consequences and contribute to diminished health, educational, and social outcomes. Research suggests that health risk behaviors exhibited during adolescence and adulthood have their origins earlier in childhood and preventive interventions are less successful after the risk behaviors have begun. Therefore, efforts to prevent health risk behaviors are best initiated in late childhood or early adolescence. However, to document the efficacy of these efforts, reliable, valid, and parent/child-friendly systems of data collection are required. Computerized data collection for research has been found to improve privacy, confidentiality, and portability over the paper-and-pencil method, which, in turn, enhances the reliability of sensitive data such as alcohol use or sexual activity. We developed programming tools for the personal computer and a handheld personal data assistant to offer a comprehensive set of user interface design elements, relational databases, and ample programming languages so that adults could answer 261 items and youth 346 items. The purpose of the article was to describe an innovative handheld computer-assisted survey interview method of collecting sensitive data with children aged 9 to 11. The method was developed as part of a large multisite, national study to prevent substance use.

Bloodstream infections in a community hospital: a 25-year follow-up.

OBJECTIVE To examine the current status of bloodstream infections (BSIs) in a community hospital as part of a 25-year longitudinal study. DESIGN Retrospective descriptive epidemiologic study. SETTING Community teaching hospital. PATIENTS All inpatients in 1998 with a positive blood culture who met the CDC NNIS System case definition of BSI. METHODS Cases were stratified by underlying illness category using case mix adjustment categories (after McCabe) and reviewed for associations among mortality, underlying illness severity, and multiple clinical and laboratory parameters. RESULTS Of 19,289 patients discharged in 1998, 185 had an episode of infection documented by blood culture (96 cases per 10,000 inpatients). BSI was twice as frequent in patients 65 years and older compared with younger patients. BSIs caused or contributed to the deaths of 22 patients for an overall case-fatality rate of 11.9% compared with 20.7% in 1982 (P = .02). Striking decreases were noted for in-hospital patient mortality in 1998 for BSIs with ultimately and rapidly fatal underlying illnesses (P = .02 and P < .10, respectively). Primary bacteremia decreased compared with 1982. Antibiotic use was vigorous, but resistance was modest in both nosocomial and community-acquired organisms and had changed little from 1982 and 1987. CONCLUSIONS Compared with previous studies, case-fatality rates in patients with BSI were substantially lower in rapidly fatal and ultimately fatal underlying illness categories. Antibiotic use was extensive but prompt and appropriate. Microorganism resistance to antibiotics changed little from the 1980s.

Pharmacoepidemiology of potential alcohol–prescription drug interactions among primary care patients with alcohol-use disorders

OBJECTIVE To report on the proportion of individuals with alcohol-use disorders who take prescription medications that could interact with alcohol and on the proportion who recall advice to avoid alcohol with their medications. DESIGN Secondary analysis of a randomized controlled trial of telephone counseling. SETTING 18 primary care practices in south-central and southeastern Wisconsin. PATIENTS 897 adults with alcohol-use disorders as identified by systematic survey. INTERVENTION Telephone and mail survey. MAIN OUTCOME MEASURES Patient-reported prescription medication use, potential for alcohol-drug interactions according to DrugDex, and patient-reported receipt of advice not to take alcohol with their medications. RESULTS Of the 869 patients who provided usable information on prescription medication use, 348 (40.0%) were taking medications with alcohol interactions or proscriptions; the most frequently reported were bupropion, selective serotonin reuptake inhibitors, and various acetaminophen-containing compounds. Slightly more than 20% of patients were taking medications with moderate to severe alcohol interactions; over one-third of these 184 patients did not recall advice to avoid alcohol. CONCLUSION Practitioners who prescribe or dispense medications may need to enhance their efforts to advise patients about alcohol-drug interactions. Prescribing and dispensing medications that interact with alcohol present opportunities to administer alcohol screens and interventions.

A Computer-Assisted System for Analysis of Interaction in Problem-Based Learning Groups

A computer-assisted system was developed to describe teaching in small groups. The system focuses on behaviors basic to the type of active, problem-solving educational experiences recently advocated for improving medical education. Raters can reliably classify the verbal communication of teachers and students by using the system s coding scheme in real time. Summary profiles are available immediately after an instructional session. Profiles disclose similarities and differences between teachers and classes and provide a feedback tool for improvement of medical teaching skills.