Robert B. Kelly

HOW VALID ARE MEDICAL RECORDS AND PATIENT QUESTIONNAIRES FOR PHYSICIAN PROFILING AND HEALTH SERVICES RESEARCH? A COMPARISON WITH DIRECT OBSERVATION OF PATIENT VISITS

OBJECTIVES This study was designed to determine the optimal nonobservational method of measuring the delivery of outpatient medical services. METHODS As part of a multimethod study of the content of primary care practice, research nurses directly observed consecutive patient visits to 138 practicing family physicians. Data on services delivered were collected using a direct observation checklist, medical record review, and patient exit questionnaires. For each medical service, the sensitivity, specificity, and Kappa statistic were calculated for medical record review and patient exit questionnaires compared with direct observation. Interrater reliability among eight research nurses was calculated using the Kappa statistic for a separate sample of videotaped visits and medical records. RESULTS Visits by 4,454 patients were observed. Exit questionnaires were returned by 74% of patients. Research nurse interrater reliabilities were generally high. The specificity of both the medical record and the patient exit questionnaire was high for most services. The sensitivity of the medical record was low for measuring health habit counseling and moderate for physical examination, laboratory testing, and immunization. The patient exit questionnaire showed moderate to high sensitivity for health habit counseling and immunization and variable sensitivity for physical examination and laboratory services. CONCLUSIONS The validity of the medical record and patient questionnaire for measuring delivery of different health services varied with the service. This report can be used to choose the optimal nonobservational method of measuring the delivery of specific ambulatory medical services for research and physician profiling and to interpret existing health services research studies using these common measures.

Adherence to screening flexible sigmoidoscopy in asymptomatic patients.

The purpose of this study was to assess patient adherence to physician-recommended screening flexible sigmoidoscopy. In the setting of a family practice residency program, adherence rates in asymptomatic patients (N = 333, age ≥50 years) were compared among a Usual Care Group; an Intervention Group that received educational materials and a phone reminder; and a Continuity Group, which had longstanding continuity with a single physician. Data from mailed questionnaires (N = 180) were used to examine the associations of demographic factors and attitudes with adherence. Adherence was 30.3% overall, with a nonsignificant increase in the Intervention Group compared with the Usual Care Group. In a pooled analysis of the Usual Care and Continuity Groups, the half of the sample with the highest continuity had a significantly higher adherence rate than the rest of the sample (45%; P < 0.001). In a discriminant analysis (78% correct classification, P < 0.001) two history variables (family history of cancer; family history of colon problems), one measure of continuity (number of physician visits), one demographic variable (lower household income), and two attitudinal factors (perception of how painful flexible sigmoidoscopy would be; perception of how well the physician explained its importance) made statistically significant contributions to the prediction of adherence. Results of the study show that screening flexible sigmoidoscopy is acceptable to asymptomatic patients, and that continuity is likely to have a positive impact on adherence. Because attitudes offer the potential for modification, we suggest that physicians reassure patients that flexible sigmoidoscopy is not unduly painful and discuss with patients individually its importance to their health.

Initiation of health behavior discussions during primary care outpatient visits

OBJECTIVE Despite the importance of health promotion, rates of health behavior advice remain low and little is known about how advice is integrated into routine primary care. This study examines how health behavior topics of diet, physical activity and smoking are initiated during outpatient visits. METHODS Audio recording of 187 adults visit to five purposefully selected physicians. An iterative analysis involved listening to and discussing cases to identify emergent patterns of initiation of health behavior talk and advice that followed. RESULTS Physicians initiated 65% of discussions and used two overarching strategies (1) Structured: a routine to ask about health behavior and (2) Opportunistic: use of a trigger to make a transition to talk about health behavior. Opportunistic strategies identified a greater proportion of patients at risk (50% vs. 34%) and led to a greater rate of advice (100% vs. 75%). Patients initiated one-third of health behavior discussions and were more likely to receive advice if they explicitly indicated readiness to change. CONCLUSIONS Opportunistic strategies show promise for a higher yield of identifying patients at risk and leading to advice. PRACTICE IMPLICATIONS Encouraging patients to be explicit about their readiness to change is likely to increase physician advice and assistance.

An ecological study of the effectiveness of mammography in reducing breast cancer mortality.

OBJECTIVES The purpose of this study was to determine the relation of screening mammography to breast cancer incidence and case fatality. METHODS In a sample of White female Medicare beneficiaries hospitalized in 1990-1991, age-adjusted breast cancer incidence and 2-year case fatality rates were estimated and compared with the frequency of mammographic screening from a population-based survey. RESULTS The average rates for incidence, case fatality, and mammography within 5 years in 29 states were 414/100,000, 18.8%, and 59.2%, respectively. There was a positive state-level correlation between mammography rates and incidence and an inverse correlation between mammography and case fatality. CONCLUSIONS High screening mammography rates in some states are associated with reduced breast cancer case fatality rates, presumably as a result of diagnosis of earlier stage cancers.

Critical success factors for promotion and tenure in family medicine departments.

PURPOSE: (1) To summarize the judgments of family medicine department leaders regarding the elements leading to success in promotion and/or tenure, and (2) to compare the views of department leaders with those of family medicine faculty who have been successfully promoted. METHOD: Two surveys were conducted. The first was of 296 associate professor members of the Society of Teachers of Family Medicine in November 1993. The second, conducted in the summer of 1994, was of all 115 U.S. members of the Association of Departments of Family Medicine; surveys were addressed to chairs, directors, or promotion and tenure committee chairs. Both survey instruments requested data regarding each respondents department, impressions about the promotion and tenure processes at the respondents institution, and general impressions regarding the characteristics of successful candidates. Comparisons of the responses to the two questionnaires were made using two-tailed t-tests; responses to open-ended questions were analyzed qualitatively by two independent investigators. RESULTS: In all, 75% of the department leaders and 67% of the associate professors returned completed questionnaires. The two groups had similar views about the importance of certain academic activities to success at promotion and tenure. The primary difference between the groups was in their estimates of weekly time available for research and writing activities: the leaders reported that successful candidates spent a mean of 25% of their work-weeks on research and writing activities; the associate professors, on the other hand, reported spending a mean of 15% of their workweeks on these activities. The department leaders described six basic groups of critical success factors. The associate professors emphasized lack of time as a major obstacle to success. CONCLUSION: The findings emphasize the critical importance of protected time for scholarly activities (such as research and writing) if generalists are to be promoted or tenured.