Meredith A. Goodwin

Direct observation of exercise counseling in community family practice

BACKGROUND Despite the large potential of dietary changes to reduce morbidity and mortality, the frequency, time spent, and factors associated with nutrition counseling in primary care are not well studied. METHODS In a cross-sectional study of 84 family physician practices in northeast Ohio, nutrition counseling was measured by direct observation on 2 days for all consecutive ambulatory visits. The frequency, time spent, and patient and visit characteristics associated with nutrition counseling were determined. RESULTS Among 138 family physicians, only 6% included nutrition counseling in the majority (>50%) of patient encounters. Among 3475 consecutive outpatient visits in adults, nutrition counseling occurred in 24% of all patient visits, 17% of visits for acute illnesses, 30% of chronic illness visits, and 41% of well-care visits. The average time spent on nutrition counseling was 55 seconds, ranging from <20 seconds to >6 minutes. Nutrition counseling occurred in 45% of visits for diabetes, 25% of visits for cardiovascular disease, 31% of visits for hypertension, 26% of prenatal visits, and 33% of visits by obese patients (body mass index >30). Nutrition counseling was more likely to occur during visits by patients who were older or had diabetes mellitus, during visits for well care or chronic illness, and during longer visits. CONCLUSION Despite considerable variability from physician to physician, nutrition counseling occurs in approximately one fourth of all office visits to family physicians. The observed efforts by family physicians to focus nutrition counseling on high-risk patients may increase its impact.

A clinical trial of tailored office systems for preventive service delivery: The Study to Enhance Prevention by Understanding Practice (STEP-UP)

BACKGROUND The potential of primary care practice settings to prevent disease and morbidity through health habit counseling, screening for asymptomatic disease, and immunizations has been incompletely met. This study was designed to test a practice-tailored approach to increasing preventive service delivery with particular emphasis on health habit counseling. DESIGN Group randomized clinical trial and multimethod process assessment. SETTING/PARTICIPANTS Seventy-seven community family practices in northeast Ohio. INTERVENTION After a 1-day practice assessment, a nurse facilitator met with practice clinicians and staff and assisted them with choosing and implementing individualized tools and approaches aimed at increasing preventive service delivery. MAIN OUTCOME MEASURE Summary scores of the health habit counseling, screening and immunization services recommended by the U.S. Preventive Services Task Force up to date for consecutive patients during randomly selected chart review days. RESULTS A significant increase (p=0.015) in global preventive service delivery rates at the 1-year follow-up was found in the intervention group (31% to 42%) compared to the control group (35% to 37%). Rates specifically for health habit counseling (p=0.007) and screening services (p=0.048) were increased, but not for immunizations. CONCLUSIONS An approach to increasing preventive service delivery that is individualized to meet particular practice needs can increase global preventive service delivery rates.

Sustainability of a practice-individualized preventive service delivery intervention.

BACKGROUND The long-term effect of most interventions has not been studied. Changes due to interventions to improve patient care may revert to baseline after the intervention stimulus ends. This analysis reports the 24-month follow-up of a practice-tailored intervention to increase preventive service delivery rates. DESIGN Group randomized clinical trial with 24-month follow-up of intervention sites. SETTING/PARTICIPANTS Seventy-seven community family practices in northeast Ohio. INTERVENTION Practice-individualized facilitation of implementation of tools and approaches. MAIN OUTCOME MEASURES Summary scores of health habit counseling, screening, and immunization services recommended by the U.S. Preventive Services Task Force that were up to date for consecutive patients during randomly selected chart review days. RESULTS Previously reported increases in global preventive service delivery rates, health habit counseling, and screening rates at 12 months were sustained after 24 months. CONCLUSIONS A practice-individualized approach can result in sustainable increases in rates of preventive service delivery, even 1 year after the outside intervention stimulus ends. Tailoring of approaches to the unique characteristics of each practice may result in institutionalization of changes.

Gender differences in time spent during direct observation of doctor-patient encounters.

BACKGROUND Despite increasing recognition of womens health needs, little is known about how primary care physicians spend time with women. Therefore, we examined differences in time use and preventive service delivery during outpatient visits by male and female patients. METHODS As part of a multimethod study of 138 family physicians, 3384 outpatient visits by adults were directly observed, medical records were reviewed, and patient surveys were performed. Time use was assessed by the Davis Observation Code, which classifies every 15 seconds into 20 behavioral categories. Receipt of health habit counseling recommended by the U.S. Preventive Services Task Force was assessed by direct observation, and eligibility was determined by chart review. Logistic regression and multivariate analysis of variance (ANOVA) were used to compare time use and preventive service delivery in visits by women vs. men. RESULTS Sixty-four percent of adult visits were from women. Women reported poorer physical health, had higher rates of anxiety (12.5% vs. 7.4% in men), and depression (21.9% vs. 8.4% in men), a higher percent of visits for well care (10.2% vs. 8.8% in men), and more drugs prescribed (64.8% vs. 61% in men) and raised more emotional issues than men (14.7% vs. 7.5%). After controlling for visit and patients characteristics, visits by women had a higher percent of time spent on physical examination, structuring the intervention, patient questions, screening, and emotional counseling. Visits by men involved a higher percent of time spent on procedures and health behavior counseling. More eligible men than women received exercise, diet, and substance abuse counseling. Patients of female physicians exhibited gender differences in only one category of how time was spent (substance abuse), whereas among patients of male physicians, gender differences were noted in 10 of the 20 categories. CONCLUSIONS Outpatient visits by women differ from those of men in ways that reflect womens unique healthcare needs but also raise concern about unequal delivery of health habit counseling for diet and exercise.

Patient-Physician Shared Experiences and Value Patients Place on Continuity of Care

PURPOSE We undertook a study to examine the impact of experiences shared between patient and physician and the value patients place on continuity of care. METHODS Data on 4,454 patients collected in The Direct Observation of Primary Care (DOPC) study conducted between October 1994 and August 1995 were analyzed to assess the value patients place on continuity, length of patient-physician relationship, and experiences shared between patient and physician. RESULTS A significant interaction was yielded between duration of relationship and experiences shared between patient and physician (P = .03). For all lengths of relationship with the physician, the value that patients have for continuity increased when patients indicated experiences shared with the physician. For patients who did not report experiences shared with the physician, the longer the relationship, the greater the value placed on continuity. CONCLUSIONS The results of this study point to the importance of the experiences shared between patients and physicians and the value that patients place on continuity with their regular physician.

Facilitating participatory decision-making: what happens in real-world community practice?

Background.Participatory decision-making (PDM), a widely held ideal, depends on physician facilitation of patient participation. However, little is known about how PDM facilitation is actualized in outpatient primary care. Objectives.The objective of this study was to describe the prevalence of physician facilitation of PDM in community family practices and associated physician, patient, and visit characteristics. Research Design.This was a cross-sectional observational study. Subjects.The study included 3,453 patients seen by 138 family physicians in 84 community practices. Main Outcome Measures.Research nurses directly observed PDM facilitation in consecutive adult outpatient visits. The association between PDM facilitation and patient, physician, and visit characteristics was assessed with multilevel multivariable regression. Results.PDM facilitation occurred during 25% of observed patient visits. Rates varied considerably among physicians, from 0% to 79% of visits. Patient satisfaction was not associated with PDM facilitation. In multivariable analyses, employed physicians, chronic illness visits, longer visit duration, and visits involving referral were independently associated with PDM facilitation. Visits in which greater time was spent planning treatment and conducting health education were also more likely to involve facilitation of PDM. Conclusions.Community family physicians facilitate PDM at highly variable rates but focus it on patients with the greatest medical needs and most complex levels of decision making. This selective approach appears to meet patient expectations, because PDM facilitation and patient satisfaction are not associated. If patient participation is to be more widely incorporated into outpatient primary care, it must be addressed within the complexity and multiple demands of community practice.

Etiology and diagnosis of bilateral leg edema in primary care

PURPOSE To identify the causes of bilateral leg edema in a primary care setting, and to determine the ability of primary care providers to arrive at the correct diagnosis using the information available at the initial clinical encounter. PATIENTS AND METHODS Fifty-eight ambulatory adult patients with bilateral leg edema were enrolled at an inner city family practice during a 3-year period. Historical information, physical examination findings, and clinical impressions of primary care providers were compared with the results of laboratory evaluations consisting of echocardiograms, venous duplex ultrasound leg scans, serum albumin levels, and when appropriate, 24-hour urinalyses. RESULTS Forty-five patients (78%) completed the study. The initial clinical impression was venous insufficiency in 32 (71%) patients and congestive heart failure in 8 (18%) patients. In actuality, 15 (33%) patients had a cardiac condition as a cause of their leg edema, and 19 (42%) had pulmonary hypertension. All of the patients with heart disease, and almost all of those with pulmonary hypertension, were age 45 years or older. Only 10 (22%) of the subjects had venous insufficiency. Renal conditions, medication use, and hypoalbuminemia were less common. CONCLUSIONS Utilizing clinical information only, many patients with cardiopulmonary pathology were incorrectly diagnosed as having more benign conditions, most commonly venous insufficiency. Echocardiographic evaluation, including an estimation of pulmonary artery pressure, may be advisable in many patients with bilateral leg edema, especially if they are at least 45 years old.

Addressing the unique challenges of inner-city practice: a direct observation study of inner-city, rural, and suburban family practices

Previous research on geographic variations in health care contains limited information regarding inner-city medical practice compared with suburban and rural settings. Our main objective was to compare patient characteristics and the process of providing medical care among family practices in inner-city, suburban, and rural locations. A cross-sectional multimethod study was conducted emphasizing direct observation of out patient visits by trained research nurses involving 4, 454 consecutive patients presenting for outpatient care to 138 family physicians during 2 days of observation at 84 community family practices in northeast Ohio. Time use during office visits was assessed with the Davis Observation Code; satisfaction was measured with the Medical Outcomes Study nine-item Visit Rating Scale; delivery of preventive services was as recommended by the US Preventive Services Task Force; and patient-reported domains of primary care were assessed with the Components of Primary Care Instrument. Results show that inner-city patients had more chronic medical problems, more emotional problems, more problems evaluated per visit, higher rates of health habit counseling, and longer and more frequent office visits. Rural patients were older, more likely to be established with the same physician, and had higher rates of satisfaction and patient-reported physician knowledge of the patient. Suburban patients were younger, had fewer chronic medical problems, and took fewer medications chronically. Inner-city family physicians in northeast Ohio appear to see a more challenging patient population than their rural and suburban counterparts and have more complex outpatient office visits. These findings have implications for health system organization along with the reimbursement and recruitment of physicians in medically underserved inner-city areas.

The Delivery of Preventive Services for Patient Symptoms

BACKGROUND Although data are available on rates of delivery of preventive services by primary care physicians, the proportion of services delivered because of related symptoms or signs, rather than for primary or secondary prevention of disease is not known. METHODS Research nurses directly observed 4454 consecutive visits to 138 practicing family physicians. Direct observation was used to identify delivery of 36 different services recommended by the U.S. Preventive Services Task Force and to assess whether delivery of these services was associated with related signs or symptoms. RESULTS One or more preventive services were delivered in 33% of visits, with rates ranging from 0.2% (HIV prevention) to 19.9% (tobacco counseling). In contrast to pure prevention, services were frequently performed for assessment or care of symptoms or signs, with the ratio ranging from 0% (eye examination; car seat, poison control, and HIV prevention counseling) to 66.7% (hearing test). Physicians varied considerably in the frequency at which their delivery of recommended preventive services was associated with patient symptoms, from 0% to 100% for screening services and from 0% to 100% for counseling services. CONCLUSIONS Because of the illness focus of most primary care visits, preventive service delivery is often associated with related signs or symptoms. Care of illnesses appears to present an important impetus and perhaps teachable moments for providing preventive care. Clinician variability in preventive service delivery for patient symptoms shows an opportunity to improve the primary and secondary prevention focus of practice to meet public health prevention goals.

The Anatomy of Asthma Care Visits in Community Family Practice

Background: We know little about the activities that occur during asthma-related visits with primary care physicians. A better understanding of how time is spent during visits for asthma may facilitate the design of programs to enhance asthma disease management. Objective: To describe the content of asthma visits made to family physicians. Methods: Research nurses directly observed consecutive outpatient visits during two separate days in the offices of 138 community family physicians. Time was classified into 20 different behavioral categories using the Davis Observation Code, and compared for visits for asthma, visits for other chronic conditions, and visits for non-asthma-related acute illnesses during 3035 visits by patients of all ages. Results: Visits for asthma shared several characteristics with visits for other chronic conditions but were longer than visits for other chronic illnesses or for acute illness. Asthma visits were distinguished from both acute care and other chronic care visits by a greater percentage of time spent discussing patient compliance, evaluating patient knowledge, and providing smoking assessment and cessation advice. Conclusions: Visits for asthma are structured differently than acute care visits and specifically address issues important to asthma self-management. Future quality improvement initiatives should recognize, affirm, and enhance many current behaviors by family physicians, while working to expand specific areas of care that still fall short of asthma care guidelines.