Does health habit counseling affect patient satisfaction?

BACKGROUND: Health behavior advice can potentially prevent a large burden of illness, but the acceptability of this advice to patients is not well understood. This study assessed whether physician discussion of behavioral risk factors decreases patient satisfaction with the outpatient visit. METHODS: In a cross-sectional study of 2,459 consecutive adult outpatient visits to 138 community family physicians in Northeast Ohio, the association of health habit counseling, measured by direct observation, with patient satisfaction, assessed by a modified subscale of the MOS 9-item visit rating scale, was calculated by logistic regression. RESULTS: In analyses controlling for patient mix, discussion of diet, exercise, alcohol and other substance use, sexually transmitted disease, and HIV prevention was not associated with patient satisfaction. Patients who were asked about their tobacco use or counseled about quitting were more likely to be very satisfied with the physician. CONCLUSIONS: Discussion of health behavior change, as practiced by community family physicians, is not associated with diminished patient satisfaction. In fact, tobacco use assessment and cessation counseling are associated with greater satisfaction.

Therapeutic touch in the treatment of carpal tunnel syndrome.

BACKGROUND: Alternative medical therapies are widely utilized, but there are few objective data to evaluate the effectiveness of these techniques. The purpose of this study was to determine whether one alternative therapy, Therapeutic Touch (TT), can improve objective indices of median nerve function in patients with carpal tunnel syndrome. METHODS: Participants with electrodiagnostically confirmed carpal tunnel syndrome were randomly assigned in single-blind fashion to receive either TT or sham therapeutic touch once weekly for 6 consecutive weeks. The distal latency of the median motor nerve along with visual analog assessments of pain and relaxation were measured before and after each treatment session. RESULTS: Twenty-one participants completed the study. Changes in median motor nerve distal latencies, pain scores, and relaxation scores did not differ between participants in the TT group and participants in the sham treatment group, either immediately after each treatment session or cumulatively. Immediately after each treatment session, however, there were improvements from baseline among all the outcome variables in both groups. CONCLUSIONS: In this small study, TT was no better than placebo in influencing median motor nerve distal latencies, pain scores, and relaxation scores. The changes in the outcome variables from baseline in both groups suggest a possible physiologic basis for the placebo effect.

Is diabetes treated as an acute or chronic illness in community family practice?

OBJECTIVE: Poor quality of diabetes care has been ascribed to the acute care focus of primary care practice. A better understanding of how time is spent during outpatient visits for diabetes compared with visits for acute conditions and other chronic diseases may facilitate the design of programs to enhance diabetes care. RESEARCH DESIGN AND METHODS: Research nurses directly observed consecutive outpatient visits during two separate days in 138 community family physician offices. Time use was categorized into 20 different behaviors using the Davis Observation Code (DOC). Time use was compared for visits for diabetes, other chronic conditions, and acute illnesses during 1,867 visits by patients > or =40 years of age. RESULTS: Of 20 DOC behavioral categories, 10 exhibited differences among the three groups. Discriminant analysis identified two distinct factors that distinguished visits for chronic disease from visits for acute illness and visits for diabetes from those for other chronic diseases. Compared with visits for other chronic diseases, visits for diabetes devoted a greater proportion of time to nutrition counseling, health education, and feedback on results and less time to chatting. Compared with visits for acute illness, visits for diabetes were longer and involved a higher proportion of dietary advice, negotiation, and assessment of compliance. CONCLUSIONS: Visits for diabetes are distinct from visits for other chronic diseases and acute illnesses in ways that may facilitate patient self-management. Novel quality-improvement interventions could support and expand existing differences between family physicians' current approaches to care of diabetes and other chronic and acute illnesses.

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.

Left ventricular dysfunction, pulmonary hypertension, obesity, and sleep apnea.

The purpose of this study was to determine the frequency of central and obstructive sleep apnea in adult patients who have echocardiographic evidence of left ventricular dysfunction and pulmonary hypertension. Subjects with left ventricular dysfunction, pulmonary hypertension (pulmonary artery systolic pressure >30 mm Hg) and no lung disease were evaluated for risk factors associated with pulmonary hypertension. Of eight eligible adults, six completed the study. Subjects were from suburban and inner city family practices. Spirometric assessment, pulse oximetry on room air, rheumatologic evaluation, polysomnography, and additional history were taken. All six subjects had sleep apnea (apnea-plus-hypopnea index, or AHI, > or = 20): obstructive, central, or mixed. All were obese, and almost all the subjects had a restrictive pattern on spirometry, which is consistent with obesity. All had a pulmonary artery systolic blood pressure of 35 mm Hg or greater. None had daytime hypoxemia or collagen vascular disease, and none had ever used appetite suppressants. This study found a strong association between pulmonary hypertension and obstructive or central sleep apnea in obese patients with congestive heart failure (CHF). We propose that a pulmonary artery systolic pressure of 35 mm Hg or greater in ambulatory patients with CHF may signify an increased risk of sleep apnea.

Bilateral leg edema, obesity, pulmonary hypertension, and obstructive sleep apnea.

BACKGROUND: Pulmonary hypertension is usually due to an underlying cardiac or pulmonary condition. An association between unexplained pulmonary hypertension and bilateral leg edema in primary care patients was found previously. We undertook this study to identify the frequency of obstructive sleep apnea (OSA) in ambulatory, adult patients with pulmonary hypertension who initially presented with bilateral leg edema. METHODS: Twenty ambulatory adults with bilateral leg edema, echocardiocardiographic evidence of pulmonary hypertension (estimated pulmonary artery systolic pressure >30 mm Hg) without left ventricular dysfunction, and no clinically apparent pulmonary disease [corrected] were enrolled from a suburban family practice and an inner-city family practice during a 3-year period. Spirometric assessment, pulse oximetry, rheumatologic evaluation, polysomnography, and questionnaire information regarding risk factors for pulmonary hypertension were obtained for each subject. RESULTS: Fifteen patients (75%) completed the study. Almost all of the subjects were obese. Nine (60%) of the 15 had OSA. None of the subjects demonstrated an obstructive pattern on spirometric evaluation results, but 9 (60%) had a restrictive spirometry pattern, consistent with their obesity. None of the subjects had daytime hypoxemia. Systemic hypertension was present in two-thirds of the subjects with OSA, and was absent in all of the subjects who lacked OSA. CONCLUSIONS: Bilateral leg edema in obese primary care patients is associated with both OSA and modest pulmonary hypertension. If these findings are generalizable, then bilateral leg edema may be an important clinical marker for underlying OSA.

Direct observation of rates of preventive service delivery in community family practice.

BACKGROUND: Data on preventive service delivery in primary care practice have been limited by indirect methods of measurement. This study describes directly observed rates of preventive service delivery during outpatient visits to community family physicians. METHODS: In a multimethod cross-sectional study, research nurses directly observed consecutive patient visits in the offices of 138 family physicians in Northeast Ohio. Patient eligibility for services recommended by the U.S. Preventive Services Task Force was determined from medical record review. Service delivery was assessed by direct observation of outpatient visits. Rates of delivery of specific preventive services were computed. Global summary measures were calculated for health habit counseling, screening, and immunization services. RESULTS: Among 4,049 visits by established patients with available medical records, wide variation was observed among rates of different preventive services delivered during well-care visits. During illness visits, rates were uniformly low for all preventive services. Counseling services were delivered at only slightly lower rates during illness visits compared to well visits. Patients were up to date on 55% of screening, 24% of immunization, and 9% of health habit counseling services. CONCLUSION: Rates of preventive service delivery are low. Illness visits are important opportunities to deliver preventive services, particularly health habit counseling, to patients. Preventive service delivery summary scores are useful in providing a patient population perspective on the delivery of preventive services and in focusing attention on delivery of a comprehensive portfolio of services.

Two physician styles of focusing on the family.

BACKGROUND: Previous research has identified 2 styles of family physicians' focus on the patient's family: (1) using the family history as the context of care of the patient; and (2) maintaining a family orientation with the family as the unit of care. The purpose of our study was to determine whether these styles affect patient outcomes and time use during outpatient visits. METHODS: In a cross-sectional study, data on 4454 outpatient visits to 138 community family physicians were collected using direct observation, patient and physician questionnaires, and medical record review. We computed partial correlations between the physician's family practice style score and patient outcomes for delivery of preventive services, patient visit satisfaction, and patient-reported delivery of specific components of primary care. We controlled for relevant patient characteristics. RESULTS: The patients of the physicians using either practice style had similar levels of satisfaction with coordination of care and interpersonal communication, and their value of continuity of care was comparable. Patients of physicians with a family-history style, however, rated their physicians lower on a measure of in-depth knowledge of the patient and family but higher on preventive services delivery. Differences in time use during the visit reflected how these styles were manifested during the outpatient visit. CONCLUSIONS: The different styles physicians use to focus on the family affect the process and outcomes of patient care. This difference may be explained by the developmental life cycle of family physicians, as younger physicians may be more focused on family history and older physicians may have a more family-oriented focus. Physicians may need to find alternate ways of meeting those patient needs not well met by their predominant practice style.

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.

Family history-taking in community family practice: implications for genetic screening.

PURPOSE: To identify characteristics of physicians, patients, and visits associated with obtaining family history information in community family practice. METHODS: Research nurses directly observed 4,454 patient visits to 138 family physicians and reviewed office medical records. RESULTS: Family history was discussed during 51% of visits by new patients and 22% of visits by established patients. Physicians' rates of family history-taking varied from 0% to 81% of visits. Family history was more often discussed at well care rather than illness visits. The average duration of family history discussions was <2.5 minutes. CONCLUSIONS: These data can form the basis for realistic interventions to increase the use of family history in primary care.

Caring for adults with mental retardation: survey of family practice residency program directors.

In their core curriculum guidelines, the Society of Teachers of Family Medicine has recognized the importance of training family physicians in caring for persons with mental retardation. We mailed surveys to all family practice residency directors in the United States, questioning them about experiences and methods used to teach residents about health care needs of adults with mental retardation and the importance of this education. We found that 84% of programs provide residents with one or more experiences, and 60% instruct residents in this area. Most directors ranked this education as very important or important. There was no relationship between type or age of residency program and likelihood that residents were educated about mental retardation. The importance of this education is discussed.

Comparison of symptoms in Japanese and American depressed primary care patients.

BACKGROUND: Depression is a highly prevalent, worldwide problem with multiple social and health consequences. It often presents in primary care with physical symptoms. Little research has been done on cross-cultural expression of depression in primary care. This paper examines the hypothesis that depressed Japanese patients present with more and with more distinct somatic complaints than depressed American patients. METHODS: Data were collected by chart audit for patients with a diagnosis of depression at two sites: Minamikawachi Tochigi, Japan and Cleveland, Ohio, USA. Patient demographics and type and number of presenting symptoms in the two populations were compared. Logistic regression was used to determine whether there were differences between countries in physical symptoms and to adjust for relevant demographic characteristics. RESULTS: Japanese family physicians charted more somatic complaints from patients diagnosed as depressed than did American family physicians. Specific physical symptoms differed by country: Japanese patients had more abdominal distress, headaches, and neck pain. These symptoms have strong cultural significance for Japanese patients. CONCLUSIONS: This study clearly indicates the prominence and importance of physical symptoms in the presentation of depression in Japanese primary care patients. Their physicians must be alerted to the possibility of depression, especially when patient complaints include abdominal, neck or head pain.

Practical tools for qualitative community-oriented primary care community assessment.

BACKGROUND AND OBJECTIVES: The evolution of managed care is creating a need for feasible methods for clinical practices to perform community assessments. Since some types of clinically useful data are best obtained through a qualitative community assessment, practical methods of carrying out this type of assessment are needed. Such practical methods are also important for community-oriented primary care, an attractive model for the marriage of population perspectives and clinical primary care. METHODS: Using methods suitable for busy clinical practices, qualitative data useful for clinical purposes were collected either by mail surveys, telephone surveys, or during focus group discussions in a low-income community. Characteristics of data obtained through each method, together with the costs, advantages, and disadvantages of each approach, were examined. RESULTS: All three methods revealed similar themes in their responses, though the range and emotional content of the responses varied by approach. Clinically useful data were obtained, although the potential for sampling and response biases must be considered. Costs, primarily related to professional time, varied by as much as 50% among the methods examined; telephone surveys were the least expensive per enrolled subject. CONCLUSIONS: The methods tested are potentially feasible in busy practices. However, practices should clarify their objectives and resources prior to using these methods.

Direct observation of health-habit counseling of adolescents.

OBJECTIVES: To determine the rate of health-habit counseling of adolescents seeing community family physicians and to identify the factors associated with the delivery of recommended preventive counseling services. DESIGN: Cross-sectional multimethod study emphasizing direct observation of patient visits. SETTING: Community family practices in northeast Ohio. PATIENTS OR OTHER PARTICIPANTS: Adolescents (n = 445) aged 11 to 21 years who were being seen for outpatient visits to community family physicians (n = 119) during 2 days of observation by trained research nurses. MAIN OUTCOME MEASURE: Direct observation of the delivery of clinical preventive counseling services recommended by the Guidelines for Adolescent Preventive Services. RESULTS: During the 445 visits made by adolescents, the most frequently delivered counseling service was exercise advice (13%). At least 1 health-habit counseling service was delivered during 38% of visits. In multivariable analyses, older patient age was strongly associated with increased service delivery. Visits for well care, longer visits, and new patient visits were also associated with the provision of counseling. Visits including preventive counseling services were on average 2.5 minutes longer than visits without preventive counseling. CONCLUSIONS: The rates of delivery of preventive counseling services in clinical practice were low, raising concern about the feasibility of current recommendations. The practical implementation of prevention guidelines may require a greater use of well-care visits and longer patient visits than are currently used in community family practice.

Primary care physicians' approach to depressive disorders. Effects of physician specialty and practice structure.

BACKGROUND: Because primary care physicians (PCPs) are the initial health care contact for most patients with depression, they are in a unique position to provide early detection and integrated care for persons with depression and coexisting medical illness. Despite this opportunity, care for depression is often suboptimal. OBJECTIVE: To better understand how to design interventions to improve care, we examine PCPs' approach to recognition and management and the effects of physician specialty and degree of capitation on barriers to care for 3 common depressive disorders. METHODS: A 53-item questionnaire was mailed to 3375 randomly selected subjects, divided equally among family physicians, general internists, and obstetrician-gynecologists. The questionnaire assessed reported diagnosis and treatment practices for each subject's most recent patient recognized to have major or minor depression or dysthymia and barriers to the recognition and treatment of depression. Eligible physicians were PCPs who worked at least half-time seeing outpatients for longitudinal care. RESULTS: Of 2316 physicians with known eligibility, 1350 (58.3%) returned the questionnaire. Respondents were family physicians (n = 621), general internists (n = 474), and obstetrician-gynecologists (n = 255). The PCPs report recognition and evaluation practices related to their most recent case as follows: recognition by routine questioning or screening for depression (9%), diagnosis based on formal criteria (33.7%), direct questioning about suicide (58%), and assessment for substance abuse (68.1%) or medical causes of depression (84.1%). Reported treatment practices were watchful waiting only (6.1%), PCP counseling for more than 5 minutes (39.7%), antidepressant medication prescription (72.5%), and mental health referral (38.4%). Diagnostic evaluation and treatment approaches varied significantly by specialty but not by the type of depression or degree of capitation. Physician barriers differed by specialty more than by degree of capitation. In contrast, organizational barriers, such as time for an adequate history and the affordability of mental health professionals, differed by degree of capitation more than by physician specialty. Patient barriers were common but did not vary by physician specialty or degree of capitation. CONCLUSIONS: A substantial proportion of PCPs report diagnostic and treatment approaches that are consistent with high-quality care. Differences in approach were associated more with specialty than with type of depressive disorder or degree of capitation. Quality improvement efforts need to (1) be tailored for different physician specialties, (2) emphasize the importance of differentiating major depression from other depressive disorders and tailoring the treatment approach accordingly, and (3) address organizational barriers to best practice and knowledge gaps about depression treatment.