Antibiotic use in acute respiratory infections and the ways patients pressure physicians for a prescription.

OBJECTIVE: We identified those aspects of physician-patient communication that influence physicians to prescribe antibiotics for respiratory infections. STUDY DESIGN: A multimethod comparative case study was performed including descriptive field notes of outpatient visits. POPULATION: We included patients (children and adults) and clinicians in 18 purposefully selected family practices in a midwestern state. A total of 298 outpatient visits for acute respiratory tract (ART) infections were selected for analysis from more than 1600 encounters observed. OUTCOMES MEASURED: Unnecessary antibiotic use and patterns of physician-patient communication were measured. RESULTS: Antibiotics were prescribed in 68% of the ART infection visits, and of those, 79% were determined to be unnecessary according to Centers for Disease Control and Prevention guidelines. Patients were observed to pressure physicians for medication. The types of patterns identified were direct request, candidate diagnosis (a diagnosis suggested by the patient), implied candidate diagnosis (a set of symptoms specifically indexing a particular diagnosis), portraying severity of illness, appealing to life-world circumstances, and previous use of antibiotics. Also, clinicians were observed to rationalize their antibiotic prescriptions by reporting medically acceptable reasons and diagnoses to patients. CONCLUSIONS: Patients strongly influence the antibiotic prescribing of physicians by using a number of different behaviors. To decrease antibiotic use for ART infections, patients should be educated about the dangers and limited benefits of such use, and clinicians should consider appropriate responses to these different patient pressures to prescribe antibiotics.

Tailoring tobacco counseling to the competing demands in the clinical encounter.

OBJECTIVES: We identified patterns of tobacco cessation counseling in primary care practices, including contextual factors that influence its provision. STUDY DESIGN: A cross-sectional study was performed using direct observation of outpatient visits. POPULATION: We included 91 outpatient visits by cigarette smokers visiting 20 family physicians in 7 Nebraska community family practices. OUTCOMES MEASURED: We measured patterns and quality of tobacco counseling assessed by direct observation. RESULTS: A hierarchy of 5 patterns was discernable, ranging from appropriate to inappropriate provision or nonprovision of tobacco cessation counseling. CONCLUSIONS: Since tobacco-specific discussions are appropriate only in approximately three fourths of primary care visits by smokers, clinical practice guidelines that recommend intervention at every visit are unrealistic. However, the finding that only one third of eligible visits addressed tobacco makes it imperative that tobacco cessation counseling be reliably integrated into visits for well care and tobacco-related illnesses that represent teachable moments.

Tools for community-oriented primary care: use of key informant trees in eleven practices.

Physicians increasingly need information about their communities to use in care of the individual patient. Busy practitioners need feasible methods for collecting this information before they can begin to gather and use it, however. Our objective was to study key informant trees as a practical approach for practice-based gathering of qualitative data from a community. Following a standard protocol, key informant trees were set up in 11 different practices to study the costs, advantages, and problems with their use for this purpose. Time studies showed that each tree took 7 to 11 hours of physician time and 7 hours of clerical time to organize and conduct. The technique appeared to be best suited for two qualitative informational needs: idea generation and explanatory data gathering. Trees appeared most productive where there was stability of physician staff in the practice, where the practice had been present in the community for some years, and where community residents were relatively stable. Response and selection biases are important considerations in use of this technique.

Exploring lay definitions of asthma and interpersonal barriers to care in a predominantly Puerto Rican, inner-city community.

Lay definitions of asthma were elicited through a single open-ended question from a population-based sample of mostly Puerto Rican, inner-city residents in Buffalo, New York. One hundred fifty-five household responses to the question, "What do you think asthma is?" were analyzed qualitatively using the editing approach. Five common codes emerged in order of significance: "symptoms," "disease," "triggers," "threat," and "coping." Overall, expressions of illness reflected a largely symptomatic perception of asthma regardless of asthma status. Perceptions of "disease" increased with higher level of education. Patients' definitions of illness should be considered to help reduce interpersonal barriers to asthma care.

Unlimited opportunities for environmental interventions with inner-city asthmatics.

The purpose of this study was to identify the asthmatics living in the Lower West Side (LWS) of Buffalo, New York, and then explore the relationship between urban asthmatic and nonasthmatic exposures to many common household aeroallergens. Eight hundred twenty-eight households were visited and 167 asthmatics and 161 nonasthmatics were identified for comparison. Specific self-reported household exposure prevalences were identified for environmental tobacco smoke, sources of molds, household pets, rats, cockroaches, and sources of dust. Sources of molds, pets, and cockroaches were more likely to be found in the homes of asthmatics compared to nonasthmatics (p < 0.05). Other aeroallergens studied, although highly prevalent, were not more likely to be found in either asthmatic or nonasthmatic homes.

Heart failure in primary care: measuring the quality of care.

BACKGROUND: Concerns exist about the quality of care provided to heart failure patients by primary care physicians. Using an evidence-based clinical guideline, we evaluated the care given to patients with systolic heart failure. METHODS: We retrospectively reviewed the medical records of 420 patients from 25 primary care practices in upstate New York who had received a diagnosis of heart failure. Chart documentation confirmed the diagnosis (n = 395). We excluded patients with noncardiogenic volume overload or correctable valvular disease (n = 338). Performance profiles measured use of diagnostic tests, left ventricular ejection fraction (LVEF) measurement, patient education, and prescription of angiotensin-converting enzyme (ACE) inhibitors. For treatment recommendations, patients were classified according to LVEF status. RESULTS: Only 82% of the patients studied had an LVEF test result documented in their charts. Of these, 49% had an LVEF < or = 40%. ACE inhibitor use was greater among patients with low LVEF (91%) than among those with a normal LVEF (62%). Among patients with systolic heart failure taking ACE inhibitors, 87% were at target doses. Adherence measures were low for laboratory evaluation and patient-education criteria. CONCLUSIONS: Heart failure with normal LVEF was as prevalent as systolic heart failure in these primary care practices. Performance profiles for the physicians' prescriptions of ACE inhibitors exceeded those published in the literature. Patients who did not have a documented measure of LVEF, however, received lower quality of care as measured by this disease-specific guideline. This underscores the importance of measuring LVEF.

Unmasking adverse birth outcomes among Hispanic subgroups.

The 1988 Upstate New York Live Birth Certificate was the first to record Hispanic ethnicity and country of origin. This registry was used to compare low birthweight and preterm delivery among non-Hispanic white, non-Hispanic black, and Hispanic infants. Risk of low birthweight and preterm delivery was assessed for Hispanics by country of origin. Unconditional backward elimination logistic regression analysis, controlling for confounders was used to assess risk of low birthweight and preterm delivery of Hispanic subgroups compared to non-Hispanic white and non-Hispanic black mothers. The data showed that non-Hispanic black mothers are at greatest risk of low birthweight and preterm delivery. Hispanics as a group have rates similar to non-Hispanic white mothers, although risk of preterm delivery and low birthweight differs among Hispanic ethnic subgroups. This study supports the need to assess Hispanic subgroups separately rather than as a single entity.

How valid are medical records and patient questionnaires for physician profiling and health services research? A comparison with direct observation of patients 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.

The value of a family physician.

BACKGROUND: Most efforts to improve health care have been made without a full understanding of the value of a primary care approach. METHODS: This article synthesizes the observations from the Direct Observation of Primary Care (DOPC) study. This multimethod study of 138 family physicians in 84 practices included direct observation of 4454 patients visits were used to describe aspects of family practice that may provide value for patients. RESULTS: Family physicians provide and coordinate care for a wide variety of patients problems, prioritizing these competing demands on the basis of relationships developed during multiple patient visits over time. They use acute and chronic illness visits as opportunities to integrate care for specific diseases, mental health, and preventive care in ways that are tailored to the specific needs of patients and families. Higher rates of delivery of core attributes of family practice are associated with patient satisfaction and preventive services delivery, and are diminished by forced discontinuity of care. CONCLUSIONS: Family physicians prioritize and deliver care according to a broad agenda based on patient needs. These needs are understood within ongoing relationships with the patient, family, larger health care system, and community. This integrative approach includes numerous avenues for affecting important patient outcomes that are unlikely to be optimally met by less integrated models of medical care. Expanding the value of family practice will require the development and application of new knowledge of the core structures, processes, and contexts of family practice, and their effects on patient outcomes.

Illuminating the 'black box'. A description of 4454 patient visits to 138 family physicians.

BACKGROUND: The content and context of family practice outpatient visits have never been fully described, leaving many aspects of family practice in a "black box," unseen by policymakers and understood only in isolation. This article describes community family practices, physicians, patients, and outpatient visits. METHODS: Practicing family physicians in northeast Ohio were invited to participate in a multimethod study of the content of primary care practice. Research nurses directly observed consecutive patient visits, and collected additional data using medical record reviews, patient and physician questionnaires, billing data, practice environment checklists, and ethnographic fieldnotes. RESULTS: Visits by 4454 patients seeing 138 physicians in 84 practices were observed. Outpatient visits to family physicians encompassed a wide variety of patients, problems, and levels of complexity. The average patient paid 4.3 visits to the practice within the past year. The mean visit duration was 10 minutes. Fifty-eight percent of visits were for acute illness, 24% for chronic illness, and 12% for well care. The most common uses of time were history-taking, planning treatment, physical examination, health education, feedback, family information, chatting, structuring the interaction, and patient questions. CONCLUSIONS: Family practice and patient visits are complex, with competing demands and opportunities to address a wide range of problems of individuals and families over time and at various stages of health and illness. Multimethod research in practice settings can identify ways to enhance the competing opportunities of family practice to improve the health of their patients.

The impact of recent emotional distress and diagnosis of depression or anxiety on the physician-patient encounter in family practice.

BACKGROUND: Primary care physicians are expected to identify mental health problems. Currently, it is unclear how a recent experience of emotional distress affects the physician-patient encounter and the diagnostic process. METHODS: Using the Davis Observation Code, we studied 1269 encounters between family physicians and adult patients who completed brief questionnaires after the visit. Patients were separated into three groups using self-report and billing data: those denying recent emotional distress, those reporting recent emotional distress but not receiving a mental health diagnosis, and those reporting recent emotional distress and receiving a diagnosis of anxiety or depression. RESULTS: Nineteen percent of patients reported significant emotional distress during the previous 4 weeks; 18% of these patients received a billing diagnosis of depression or anxiety. Patients not reporting emotional distress had the shortest visits (10.0 minutes); recent emotional distress was associated with significantly longer visits: 11.5 minutes for those without a diagnosis of depression or anxiety and 12.8 minutes for those with a diagnosis of depression or anxiety. The visits of patients with a diagnosis of depression or anxiety included more counseling, history-taking, and discussions of family information and substance use, and less time providing physical examination and evaluation feedback. Fewer preventive services and less chatting occurred when patients reported recent distress, regardless of diagnosis. CONCLUSIONS: Recent patient emotional distress has a powerful impact on the structure of the family practice visit, with important implications for efforts to enhance diagnosis and treatment of mental health issues. The challenge for the family physician is to recognize and treat a patient's emotional distress while continuing to fulfill competing medical demands.

Making time for tobacco cessation counseling.

BACKGROUND: The objective of this study was to examine the incidence, targeting, and time demands of tobacco cessation advice by community family physicians. METHODS: Research nurses directly observed 2 days of outpatient visits to 138 family physicians in northeast Ohio. Smoking status was identified by patient questionnaire. Visit characteristics were determined from direct observation and billing data. Visits by smokers with and without smoking cessation advice were compared. RESULTS: The incidence of tobacco cessation advice was highest during wellness visits (55% vs 22% for illness visits; P < .001). Smokers seen for a tobacco-related chronic illness were more likely to receive advice than those seen for a chronic problem not related to tobacco (32% vs 17%; P = .05). The average duration of advice was less than 1 1/2 minutes. There were no significant differences in the duration of advice across different types of visits. CONCLUSIONS: Physicians are providing brief, targeted interventions for smoking cessation in family practices. The findings support the feasibility of implementing a brief intervention with all smokers seen during office visits.

Patterns of dysphoria in a Puerto Rican urban community.

This study was undertaken to explore the prevalence of perceived dysphoria in a poor, urban, predominantly Puerto Rican community. A cross-sectional sample of 704 adult respondents were asked a single validated question, with a five-item Likert scale response, about their level of perceived dysphoria. Chi-squared analysis and Spearman's correlation coefficients were used to assess the association of level of dysphoria with social characteristics, barriers to health care, health status, and substance use. Linear regression modeling was used to control for confounding variables. Twenty percent of the respondents were dysphoric. Respondents with no health insurance or no source of health care were least likely to be dysphoric. Persons who perceived distance to the hospital and the doctor, and understanding language of the doctor and office staff as barriers to care were more likely to be dysphoric. Ethnicity was not correlated with level of perceived dysphoria; however, age, gender, and health status were found to be associated with level of dysphoria after controlling for other correlated variables. These results indicate that the psychological needs of communities need to be understood and interventions that are appropriate for the population need to be devised.

Missed opportunities for prevention: smoking cessation counseling and the competing demands of practice.

BACKGROUND: Smoking cessation advice is an effective intervention for the control of tobacco use. The objective of this study was to assess and describe the rates of smoking status assessment and smoking cessation advice provided by physicians during ambulatory office visits with respect to physician specialty, type of visit, and number of problems addressed at the visit. METHODS: We used a cross-sectional survey of patient visits to the offices of nonfederally employed, office-based physicians participating in the 1992 National Ambulatory Medical Care Survey (n = 1558). RESULTS: Physicians reported knowing the smoking status of their patients in 66% of outpatient visits. The rate of assessment was similar for generalists and specialists. Cardiologists and generalists, except for pediatricians, showed discernible rates of smoking cessation advice (medians ranging from 14% to 50%), whereas obstetrician/gynecologists and other specialists had negligible rates. For tobacco-related visits, generalists and specialists had comparable rates of cessation advice to identified smokers. For non-tobacco-related visits, generalists had higher rates than specialists (22% vs 10%; P < .001). CONCLUSIONS: Although a substantial majority of smokers are reportedly identified by physicians during ambulatory visits, a large number of identified smokers are not receiving smoking cessation counseling. Patients seen by generalists are more likely to receive smoking cessation advice. Physicians appear to prioritize smoking cessation advice based on diagnosis at the time of the visit.

Using a clinical practice guideline to measure physician practice: translating a guideline for the management of heart failure.

BACKGROUND: Effective clinical practice guidelines should improve clinical outcomes, and measures of physician use of clinical practice guidelines should correlate with improved outcomes. This study translates a clinical practice guideline on heart failure into review criteria to measure physician performance and the effectiveness of the clinical practice guideline. METHODS: A panel of 11 family physicians and 1 cardiologist systematically reviewed the clinical practice guideline for its clinical importance, educational relevance, and evaluative appropriateness. Then a subset of 4 family physicians rigorously applied each recommendation to established criteria for measurability and developed an evaluation tool useful in medical record review. RESULTS: The heart failure clinical practice guideline was found to be an excellent educational tool. Using it to measure physician performance, however, was limited to diagnostic tests and drug prescribing. Of 45 recommendations, 5 fulfilled criteria for measurability; 1 recommendation had A-level evidence, whereas 2 recommendations had B-level and 2 had C-level evidence. CONCLUSION: This study illustrates the logistic issues and challenges in developing a measure of physician adherence to clinical practice guidelines. Medical record review is inadequate to measure many recommendations. Physicians use of this clinical practice guideline must be evaluated as an intermediate step to measuring the effectiveness of clinical practice guidelines based on patient outcomes.