Patient-physician fit: an exploratory study of a multidimensional instrument.

BACKGROUND: Patients face difficulty selecting physicians because they have little knowledge of how physicians' behaviors fit with their own preferences. OBJECTIVE: To develop scales of patient and physician behavior preferences and determine whether patient-physician fit is associated with patient satisfaction. DESIGN: Two cross-sectional surveys of patients and providers. SETTING: Ambulatory clinics at a university medical center. Participants. Eight general internists, 14 family physicians, and 193 patients. MEASUREMENTS: Two instruments were developed to measure 6 preferences for physician behaviors: 1) considering nonmedical aspects of the patient's life, 2) familiarity with herbal medicine, 3) physician decision making, 4) providing information, 5) considering the patient's religion, and 6) treating what the patient perceives as his or her problem. Patients reported how they would prefer physicians to behave, and physicians reported how they preferred to behave. Patients also rated satisfaction with their physician. RESULTS: Post hoc tests found that as a group, patients scored higher than physicians in preference for the physician to provide information and lower in preference for considering nonmedical aspects of the patient's life and religious beliefs. As hypothesized, preference differences accounted for significant variance in satisfaction in overall tests (19% in the family medicine patients and 25% in internal medicine patients). Greater satisfaction was associated with fit between patient and physician preferences for physician decision making (in the internal medicine patients) and with fit in providing information and consideration of religion (in family medicine patients) CONCLUSIONS: Patients often prefer behaviors other than how their physicians prefer to behave. Preference fit is associated with enhanced patient satisfaction. Physicians should attend to whether patients want religion and other nonmedical aspects of their lives considered. Health plans may wish to provide tools to help patients choose physicians by fit.

Concordance between respondent self-reports and medical records for chronic conditions: experience from the Veterans Health Study.

Researchers have frequently relied on case identification using clinician-based screening as the standard. This study evaluates a self-administered screening questionnaire developed for use in the Veterans Health Study. We compared concordance between elderly patients' reports of selected chronic illnesses and the medical record. The purpose of this study was to determine the feasibility of using a self-report screening questionnaire for case identification in an outcomes study of elderly respondents. Reports of the presence of selected chronic illnesses were compared in a sample of patients (N=402) receiving outpatient care between 2 data sources, patient self-report and medical record, to determine overall concordance in 5 common chronic conditions (hypertension, adult-onset diabetes mellitus, chronic low-back pain, osteoarthritis of the knee, and chronic lung disease). Discordance between the 2 data sources varied by condition. Differences in reporting were small for diabetes and hypertension, intermediate for chronic lung disease, and larger for osteoarthritis of the knee and chronic low-back pain, where the chart did not identify substantial proportions of cases reported in the questionnaire. Use of patient-reported screening questionnaires, which are self-administered, is a valid, cost-efficient method to identify some chronic illnesses. Using medical records alone may result in underestimation of some symptom-based conditions.

Preliminary validation of a patient-based self-assessment measure of severity of illness in type 2 diabetes: results from the pilot phase of the Veterans Health Study.

Measures of case mix are needed to control for patients' clinical status in studies assessing the process and outcomes of care. The Veterans Health Study (VHS) is a longitudinal study of determinants of health outcomes in ambulatory veterans. This study assessed the validity of a case-mix measure developed to quantify severity of illness in ambulatory type 2 diabetic patients. As part of the pilot phase of the VHS, 245 veterans using 4 primary care clinics in Boston were screened for diabetes and 5 other chronic illnesses when they presented for care. Subjects screening positive for diabetes returned to complete severity of illness and outcome measures. The variables for the diabetes case-mix module were chosen based upon the principles of parsimony, duration of follow-up, and clinical validity and credibility. Variables were selected to predict function, as measured by the Medical Outcomes Study Short-Form 36 (SF-36). The diabetic patients in this study had a heavy burden of chronic illness, with an average of 3.9 comorbid conditions and a mean general health perceptions score of 48 on the SF-36 (scored from 0 to 100, with 100 indicating best health). A summary variable called DMSEV was created for "diabetes severity". This included atherosclerotic complications(stroke, transient ischemic attack or myocardial infarction; chest pain frequency; and claudication), plus any history of eye, foot, or neuropathic symptoms. DMSEV correlated with all 8 outcome scales of the SF-36, and in particular was highly associated with physical function (r=0.49, P=.0001). Least squares linear regression analysis controlling for age and comorbidity confirmed the association of DMSEV with all 8 SF-36 scales. The correlation with physical function remained highly significant (P<.0001), with an R of 0.31. This patient-based self-assessment questionnaire and the summary variable DMSEV appear to be valid measures of severity of illness in ambulatory diabetic veterans with multiple comorbidities. After further testing, this case-mix measure may be suitable for controlling for severity of illness in ambulatory-based studies of diabetic patients with multiple chronic illnesses.