Thomas L. Campbell

Patient-Centered Communication and Diagnostic Testing

PURPOSE Although patient-centered communication is associated with improved health and patient trust, information about the impact of patient-centered communication on health care costs is limited. We studied the relationship between patient-centered communication and diagnostic testing expenditures. METHODS We undertook an observational cross-sectional study using covert standardized patient visits to study physician interaction style and its relationship to diagnostic testing costs. Participants were 100 primary care physicians in the Rochester, NY, area participating in a large managed care organization (MCO). Audio recordings of 2 standardized patient encounters for each physician were rated using the Measure of Patient-Centered Communication (MPCC). Standardized diagnostic testing and other expenditures, adjusted for patient demographics and case-mix, were derived from the MCO claims database. Analyses were adjusted for demographics and standardized patient detection. RESULTS Compared with other physicians, those who had MPCC scores in the lowest tercile had greater standardized diagnostic testing expenditures (11.0% higher, 95% confidence interval [CI], 4.5%–17.8%) and greater total standardized expenditures (3.5% higher, 95% CI, 1.0%–6.1%). Whereas lower MPCC scores were associated with shorter visits, adjustment for visit length and standardized patient detection did not affect the relationship with expenditures. Total (testing, ambulatory and hospital care) expenditures were also greater for physicians who had lower MPCC scores, an effect primarily associated with the effect on testing expenditures. CONCLUSIONS Patient-centered communication is associated with fewer diagnostic testing expenditures but also with increased visit length. Because costs and visit length may affect physicians’ and health systems’ willingness to endorse and practice a patient-centered approach, these results should be confirmed in future randomized trials.

Social relationships and health: The relative roles of family functioning and social support

The associations between social relationships and health have been examined using two major research traditions. Using a social epidemiological approach, much research has shown the beneficial effect of social supports on health and health behaviors. Family interaction research, which has grown out of a more clinical tradition, has shown the complex effects of family functioning on health, particularly mental health. No studies have examined the relative power of these two approaches in explicating the connections between social relationships and health. We hypothesized that social relationships (social support and family functioning) would exert direct and indirect (through depressive symptoms) effects on health behaviors. We also hypothesized that the effects of social relationships on health would be more powerfully explicated by family functioning than by social support. We mailed a pilot survey to a random sample of patients attending a family practice center, including questions on depressive symptoms, cardiovascular health behaviors, demographics, social support using the ISEL scale, and family functioning using the FEICS scale. FEICS is a self-report questionnaire designed to assess family emotional involvement and criticism, the media elements of family expressed emotion. Eighty-three useable responses were obtained. Regression analyses and structural modelling showed both direct and indirect statistically significant paths from social relationships to health behaviors. Family criticism was directly associated (standardized coefficient = 0.29) with depressive symptoms, and family emotional involvement was directly associated with both depressive symptoms (coefficient = 0.35) and healthy cardiovascular behaviors (coefficient = 0.32). The results support the primacy of family functioning factors in understanding the associations among social relationships, mental health, and health behaviors. The contrasting relationships between emotional involvement and depressive symptoms on the one hand and emotional involvement and health behaviors on the other suggest the need for a more complex model to understand the connections between social relationships and health.

Does Enhancing Partner Support and Interaction Improve Smoking Cessation? A Meta-Analysis

BACKGROUND We wanted to determine whether an intervention to enhance partner support helps as an adjunct to a smoking cessation program. METHODS We undertook a meta-analysis of English-language, randomized controlled trials of smoking cessation interventions through July 2002 using the following data sources: Cochrane Tobacco Addiction Group specialized register, Cochrane controlled trials register, CDC Tobacco Information and Prevention Database, MEDLINE, Cancer Lit, EMBASE, CINAHL, PsycINFO, ERIC, PsycLIT, Dissertation Abstracts, SSCI and HealthSTAR, with reviews of bibliographies of included articles. Included were trials that assessed a partner support component with a minimum follow-up of 6 months. The outcomes measured were abstinence and biochemical assessment at 6 to 9 months and more than 12 months after treatment. Partner Interaction Questionnaire scores were primary and secondary outcomes. RESULTS Nine studies (31 articles) met inclusion criteria. Partner definition varied among studies. All studies included self-reported smoking cessation rates, but there was limited biochemical validation of abstinence. For self-reported abstinence at 6 to 9 months after treatment, the Peto odds ratio (OR) = 1.08 (95% confidence interval [CI], 0.81–1.44) and at 12 months Peto OR = 1.0 (95% CI, 0.75–1.34). Sensitivity analysis of studies using live-in, married, and equivalent-to-married partners found a higher odds ratio at 6 to 9 months after treatment, Peto OR = 1.64 (95% CI, 0.5–4.64). Sensitivity analysis of studies reporting significant increases in partner support found at 6 to 9 months after treatment Peto OR = 1.83 (95% CI, 0.9–3.47); and at 12 months Peto OR =1.22 (95% CI, 0.67–2.23). CONCLUSIONS Interventions to enhance partner support showed the most promise for clinical practice when implemented with live-in, married, and equivalent-to-married partners. Such interventions should focus on enhancing supportive behaviors, while minimizing behaviors critical of smoking.

Physician Perspectives on Incentives to Participate in Practice-based Research: A Greater Rochester Practice-Based Research Network (GR-PBRN) Study

Objectives: To understand factors associated with primary care physician research participation in a practice-based research network (PBRN) and to compare perspectives by specialty. Methods: We surveyed primary care internists, family physicians, and pediatricians in Monroe County, New York, regarding their past experience with research and incentives to participate in practice-based research. We performed descriptive and tabular analyses to assess perceptions and used χ2 and analysis of variance to compare perceptions across the 3 specialties. Results: The response rate was 33%. The most frequently endorsed aspects of collaboration were the opportunity to enact quality improvement (78%), contribution to clinical knowledge (75%), and intellectual stimulation (65%). Significant differences among the primary care specialties were found in 2 aspects: (1) internists were more likely to endorse additional source of income as “important,” and family medicine physicians were more likely to cite the opportunity to shape research questions, projects, and journal articles as “important.” Conclusion: Physicians across all 3 specialties cited the opportunity to enact quality improvement and contribution to clinical knowledge as important incentives to participating in practice-based research. This supports the importance of strengthening the interface between research and quality improvement in PBRN projects. Further study is needed to assess reasons for differences among specialties if PBRNs are to become successful in research involving adult patients.

The four pillars for primary care physician workforce reform: A blueprint for future activity

82 Max has been a member of the Governing Board of the Student Outreach Resource Center (SOURCE) at Johns Hopkins for 3 years. He is a co-leader of his medical school’s Urban Health Interest Group and Family Medicine Interest Group, he sat on the board of the Maryland Academy of Family Physicians Foundation, and he served as a Student Delegate to the National Congress of Student Members of the American Academy of Family Physicians (AAFP). Recently, Max was appointed to a 1-year term on the AAFP’s Commission on Health of the Public and Science and was named a Sommer Scholar at the Johns Hopkins Bloomberg School of Public Health. As a future family physician, Max looks forward to practicing community-based primary care and preventive medicine. He wants to bring innovative models of primary care delivery to underserved communities and provide coordinated, comprehensive, and compassionate care to his patients.

Conducting a Family Conference

Much has been recommended and written about seeing the family together in the medical setting (1–3). However, the specifics of conducting a family conference have yet to be spelled out. That is the purpose of this chapter. We will offer a concrete, step-by-step guide to conducting a family conference in a medical setting. It is not the only way to conduct a family conference, but is one effective way to conduct a family conference.

ELECTRONIC HEALTH RECORDS IN ACADEMIC FAMILY MEDICINE PRACTICES: A TALE OF PROGRESS AND OPPORTUNITY

The Future of Family Medicine report called for an electronic health record (EHR) that assures integration of clinical information; provides decision-support based on evidence-based guidelines; generates chronic disease registries; tracks health maintenance interventions; and supports practice-based research and quality improvement activities. Yet, the substantial organizational, financial, and intellectual challenges of implementing EHRs in academic departments have been previously outlined.1 ADFM recently conducted an all-member electronic survey (response rate 61%) to assess the status of implementation within the context of these challenges. Sixty-two percent of the department clinical practices are owned by their universities and 25% by their sponsoring hospital. The overwhelming majority (89%) include faculty and learners practicing together, highlighting the imperative we have to model effective practice redesign. Nearly all respondents have either implemented EHRs (72%) or plan to within the next 12 months (18%). Use of EHRs is a relatively new experience for departments, with 64% reporting use for 5 years or less. This level of incorporation is likely enabled by the fact that the majority of these systems are owned and upgraded by the university (38%) or health system (34%), with only 12% of departments owning their own EHRs. Clinical information is largely recorded (61%) through a mix of template and free-text entry. Nearly all EHRs (87%) have prescription writer capabilities, and 89% provide drug safety information at the point-of-care. However, only 38% provide drug cost information and fewer than one-half (49%) provide drug information handouts for patients. In nearly two-thirds (65%) of cases, lab studies and other ancillaries flow into the chart electronically, allowing for serial comparisons. Quality improvement capabilities of EHRs are insufficient. Over one-half (53%) report having no built-in point-of-care decision support; though nearly one-third (29%) plan to have such within the year. Only 42% of the time is decision support available for clinical preventive services, while fewer than one-third (31%) of respondents report having chronic disease care reminders. Lack of patient registries is a similar barrier to the provision of high quality disease care, with an astonishing 61% of departments reporting that they do not have a functioning registry within their EHR. A number have addressed this by creating or purchasing their own superimposed registry. Two-thirds (67%) of respondents regularly measure quality indicators for their practice(s) as a whole, and one-half (52%) do so for individual clinicians in the practice. Fewer than one-half (49%) of academic practices have HIPAA-compliant Web access for patients. For those who do, 31% have a Web site for practice information; 26% allow patients to request appointments; and 23% have capability for patients to request prescription refills. Only 15% allow for e-visits with a nurse or clinician, while only 8% allow patients electronic access to portions of their health record. Academic practices face 2 imperatives: providing high quality care to their patients, and effectively demonstrating elements of the patient-centered medical home to students, residents, and our parent health systems. This survey of academic departments suggests that EHRs are quickly becoming a reality in our teaching practices. While we have benefited from the start-up capital and technologic expertise offered by our large, affiliated health science centers, we are also struggling with the challenges of slow implementation and lack of incorporation of important items such as decision support, registry use, quality indicator reporting, and electronic communication that are hallmarks of the Future of Family Medicine report. Our departments must take an active role in the redesign of our teaching practices to be patient-centered medical homes (PC-MH), maximally utilizing available technology to aid in this journey. Our parent health systems may not share this vision, and thus, may not be responsive to our needs and requests. Hiring or training faculty members who are technologically savvy will help develop the internal expertise we need to modify our EHRs for more rapid improvement efforts. We must also be strong advocates for, and demonstrate the effectiveness of, a well-designed ambulatory EHR in helping us provide higher quality care at a lower cost to the patient and the health system. This initially may require creating or purchasing our own “add-ons”, such as disease registries or secure practice Web sites for e-visits. Ultimately, playing a central leadership role in system-wide EHR implementation or revisions will likely to produce substantially better, and more sustainable, results. Much education remains to be done, and there is a compelling need for us to find ways to sell this vision to our health systems, lest we lose the opportunity to truly model patient-centered practice to our learners.

The Birth of a Family

Participating in the care of a couple’s pregnancy and the birth of a baby is one of the most rewarding experiences for family-oriented physicians. Physicians have an opportunity to have a major impact on patients and their families during this critical stage of family development. During pregnancy, the physician has extended contact with the family and usually becomes a trusted consultant (1). Families rely on their physician for most of their information about the pregnancy (2). Family-oriented pregnancy care builds upon traditional obstetrical care, providing an integrated approach that attends to the psychosocial needs of the woman and the family as well as the biomedical aspects of the pregnancy. In addition to the rewards of attending deliveries, the family-oriented physician who practices obstetrics can have a more varied and challenging practice and provides more pediatric, gynecological, and surgical care than those who do not practice obstetrics (3).

Conducting a Family Interview

Interviewing the family assists the clinician in adopting a broader biopsychosocial perspective for treating illness and disease. By asking other family members to come to the interview, the physician implies that a health problem extends beyond the office and affects more than just the patient. For some family members, this may be the first time anyone has acknowledged that they are important and may be suffering as well as the identified patient. Family meetings provide an opportunity for the patient to receive support and validation from other family members and for the clinician to recognize and deal with any significant unresolved conflict that may be affecting the illness or its treatment.

ADFM’S 2013 WINTER MEETING FOCUS: MOVING TO VALUE-BASED HEALTH CARE

The 2013 ADFM Winter Meeting’s theme was Leading in the Time of Transition from Volume-Based to Value-Based Health Care. At the core of the meeting’s program was a day-long session facilitated by Harold Miller, Executive Director of the Center for Healthcare Quality and Payment Reform, who