Competing demands in the office visit: what influences mammography recommendations?

BACKGROUND: The multiple competing demands of the busy office visit have been shown to interfere with delivery of preventive services. In this study we used physician recommendations for screening mammography to examine the relative importance of physician, patient, and visit characteristics in determining on which patient visits this preventive service will be provided. METHODS: Physicians in the Ambulatory Sentinel Practice Network (ASPN) completed a questionnaire describing their knowledge, attitudes, and beliefs about screening mammography. They also described the content of a series of nonacute care visits with women aged 40 to 75 years with regard to making a recommendation when the patient was due for screening mammography. The data were linked, and univariate and multivariate logistic regression methods were used to examine the relative importance of physician, patient, and visit characteristics on making a recommendation for mammography. RESULTS: Ninety-three physicians reported making a recommendation for screening mammography on 53.1% of nonacute visits. When modeling physician, patient, and visit characteristics separately, 70% of the variability in the model is explained by physician characteristics only, 63% by patient characteristics only, and 73% by visit characteristics only. A combined model using all characteristics explained 85% of the variability. CONCLUSIONS: Although characteristics of physicians and patients can predict frequency of recommendations for mammography, the specific characteristics of the visit are equally important. Efforts to improve delivery of preventive services in primary care that emphasize physician education and performance feedback are unlikely to increase rates of mammography recommendation. Effective strategies must consider the multiple competing demands faced by patients and physicians during each office visit and seek ways for assisting them in setting rational priorities for services.

Resolving disparities in antidepressant treatment and quality-of-life outcomes between uninsured and insured primary care patients with depression.

BACKGROUND: Efforts to improve primary care depression treatment should penetrate to vulnerable uninsured populations. OBJECTIVE: To assess a primary care intervention's impact on treatment and quality-of-life outcomes in uninsured and insured depressed patients during the acute treatment phase. RESEARCH DESIGN: Twelve community primary care practices were randomized to 'enhanced' (intervention) and usual care conditions. Physicians, nurses and administrative staff in enhanced care practices received training to improve detection and management of depression. SUBJECTS: In 1996 to 1997, 383 nonelderly depressed patients who were either uninsured or covered by private insurance/Medicaid were enrolled; 343 (89.6%) completed six-month follow-up. MEASURES: Adequate pharmacotherapy (>or=3 months of antidepressants at therapeutic doses); adequate psychotherapy (>or=8 counseling visits); improvement in mental-health-related-quality-of-life (MHQOL), assessed by Mental Component Summary scale for SF-36. RESULTS: Multivariate results showed that 54.6% of uninsured enhanced care (UEC) patients received adequate pharmacotherapy, compared with 14.3% of uninsured usual care (UUC) patients (P = 0.0005); however, receipt of adequate psychotherapy was comparable between these two groups (18.2% UEC, 11.9% UUC; P = 0.42). Intervention effects on insured patients' treatment were modest to minimal. Among usual care patients, the insured had 5.4 points greater improvement in MHQOL at 6 months than the uninsured (12.4 points insured, 7.0 points uninsured; P = 0.02); however, among patients receiving the intervention, the insured and uninsured had comparable MHQOL improvement (12.3 points insured, 11.6 points uninsured; P = 0.76). CONCLUSIONS: The intervention improved antidepressant treatment rates in uninsured patients and helped resolve quality-of-life outcome disparities observed between insured and uninsured patients receiving usual care.

Does the family APGAR effectively measure family functioning?

BACKGROUND: The Family APGAR has been widely used to study the relationship of family function and health problems in family practice offices. METHODS: Data were collected from 401 pediatricians and family physicians from the Pediatric Research in Office Settings network and the Ambulatory Sentinel Practice Network. The physicians enrolled 22,059 consecutive office visits by children aged 4 to 15 years. Parents completed a survey that included the Family APGAR and the Pediatric Symptom Checklist. Clinicians completed a survey that described child psychosocial problems, treatments initiated or continued, and specialty care referrals. RESULTS: Family dysfunction on the index visit often differed from dysfunction at follow-up (kappa=0.24). Only 31% of the families with positive Family APGAR scores at baseline were positive at follow-up, and only 43% of those with positive scores at follow-up had a positive score at the initial visit. There were many disagreements between the Family APGAR and the clinician. The Family APGAR was negative for 73% of clinician-identified dysfunctional families, and clinicians did not identify dysfunction for 83% of Family APGAR-identified dysfunctions (kappa=0.06). CONCLUSIONS: Our data do not support the use of the Family APGAR as a measure of family dysfunction in the primary care setting. Future research should clarify what it does measure.

Care of the secondary patient in family practice. A report from the Ambulatory Sentinel Practice Network.

BACKGROUND: Care of a secondary patient (an individual other than the primary patient for an outpatient visit) is common in family practice, but the content of care of this type of patient has not been described. METHODS: In a cross-sectional study, 170 volunteer primary care clinicians in 50 practices in the Ambulatory Sentinel Practice Network reported all occurrences of care of a secondary patient during 1 week of practice. These clinicians reported the characteristics of the primary patient and the secondary patient and the content of care provided to the secondary patient. Content of care was placed in 6 categories (advice, providing a prescription, assessment or explanation of symptoms, follow-up of a previous episode of care, making or authorizing a referral, and general discussion of a health condition). RESULTS: Physicians reported providing care to secondary patients during 6% of their office visits. This care involved more than one category of service for the majority of visits involving care of a secondary patient. Advice was provided during more than half the visits. A prescription, assessment or explanation of symptoms, or a general discussion of condition were provided during approximately 30% of the secondary care visits. Secondary care was judged to have substituted for a separate visit 60% of the time, added an average of 5 minutes to the visit, and yielded no reimbursement for 95% of visits. CONCLUSIONS: Care of a secondary patient reflects the provision of potentially intensive and complex services that require additional time and are largely not reimbursed or recognized by current measures of primary care. This provision of secondary care may facilitate access to care and represent an added value provided by family physicians.

Competing demands from physical problems: effect on initiating and completing depression care over 6 months.

OBJECTIVE AND DESIGN: To evaluate a cohort of patients with major depression to examine the effect of competing demands on depression care during multiple visits over 6 months. PARTICIPANTS AND SETTING: Ninety-two patients with 5 or more symptoms of depression and no recent depression treatment were evaluated by 12 primary care physicians in 6 practices in the usual-care arm of an effectiveness trial of the Agency for Health Care Policy and Research Depression Guidelines. MAIN OUTCOME MEASURE: Treatment was considered to be initiated if the patient reported starting a guideline-concordant antidepressant medication or making a visit for specialty counseling. Treatment completion was defined as either a 3-month course of guideline-concordant antidepressant use or completion of 8 or more specialty counseling visits. RESULTS: Among the 92 patients reporting no recent treatment at study enrollment, 57% reported starting and 17% reported completing a course of guideline-concordant antidepressant medication and or specialty counseling at the 6-month interview. The severity of physical problems among patients with high enthusiasm for depression treatment decreased the odds that patients would initiate depression therapy. Severity of physical problems had no observable effect on completing depression therapy in the group of patients who initiated treatment. CONCLUSIONS: Physical problems compete with depression for attention over multiple visits in untreated patients who are enthusiastic about getting care for their emotional problems. Interventions are needed for this high-risk group, because depression treatment could potentially enhance patients' treatment of their physical problems. Arch Fam Med. 2000;9:1059-1064

Designing and implementing a primary care intervention trial to improve the quality and outcome of care for major depression.

Complex interventions, which have been shown to improve primary care depression outcomes, are difficult to disseminate to routine practice settings. To address this problem, we developed a brief intervention to train primary care physicians and nurses employed by the practice to improve the detection and management of major depression. Before recruitment began, the research team conducted academic detailing conference calls with primary care physicians and nurses, and provided in-person training with nurses and administrative staff. Administrative staff screened over 11,000 patients before their visits to identify those with probable major depression. Primary care physicians delegated increased responsibility to office nurses, who educated over 90% of patients about effective depression treatment and systematically monitored their progress over time. Early results demonstrate that community primary care practices can rebundle traditional team roles over the short-term to provide more systematic mental health treatment without adding additional personnel. A rigorous evaluation of this effort will reduce time-consuming, expensive, and often unsuccessful efforts to "translate" research intervention findings into everyday practice.

Alcohol-related discussions in primary care: a report from ASPN. Ambulatory Sentinel Practice Network.

BACKGROUND: Problem drinking is common, and a 15-minute intervention can help some patients reduce drinking to safe levels. Little is known, however, about the frequency and duration of alcohol-related discussions in primary care. METHODS: Nineteen clinicians in the Ambulatory Sentinel Practice Network (ASPN) collected data about alcohol-related discussions for 1 week following their usual office routine (Phase 1) and for 1 week with the addition of routine screening for problem drinking (Phase 2). Of those, 15 clinicians collected data for a third week after receiving training in brief interventions with problem drinkers (Phase 3). Clinicians collected data on standard ASPN reporting cards. RESULTS: In Phase 1 the clinicians discussed alcohol during 9.6% of all visits. Seventy-three percent of those discussions were shorter than 2 minutes long, and only 10% lasted longer than 4 minutes. When routine screening was added (Phase 2), clinicians were more likely to discuss alcohol at acute-illness visits, but the frequency, duration, and intensity of such discussions did not change. Only 32% of Phase 2 discussions prompted by a positive screening result lasted longer than 2 minutes. After training, the duration increased (P <.004). In Phase 3, 58% of discussions prompted by a positive screening result lasted longer than 2 minutes, but only 26% lasted longer than 4 minutes. CONCLUSION: Routine screening changed the kinds of visits during which clinicians discussed alcohol use. Training in brief-intervention techniques significantly increased the duration of alcohol-related discussions, but most discussions prompted by a positive screening result were still shorter than effective interventions reported in the literature.

A primary care intervention for depression.

To assess a guideline-based intervention's impact on depression care provided in rural vs. urban primary care settings, 12 community primary care practices (four rural, eight urban) were randomized to enhanced (i.e., intervention) and usual care study conditions. The study enrolled 479 depressed patients, with 432 (90.2 percent) completing telephone follow-up at six months. Multilevel analytic models revealed that rural enhanced care patients had 2.70 times the odds (P = 0.02) of rural usual care patients of taking a three-month course of antidepressant medication at recommended dosages in the six months following baseline; urban enhanced care patients had 2.43 times the odds compared with their urban usual care counterparts (P = 0.007). Rural enhanced care patients had 3.00 times the odds of rural usual care patients of making eight or more visits to a mental health specialist for counseling in the six months following baseline (P = 0.03). Comparisons of patients in enhanced care practices showed that rural enhanced care patients had 2.00 times the odds (P = 0.12) of urban enhanced care patients of making at least one visit to a mental health specialist for counseling in the six months following baseline and had comparable odds to urban enhanced care patients (odds ratio [OR] = 1.06, P = 0.77) of making eight or more visits to such specialists during that interval. The study's intervention improved the care received by both rural and urban depressed primary care patients. Moreover, the intervention's effect appears to have been greater in rural settings, particularly in terms of increasing depressed rural patients' use of mental health specialists for counseling.

Practice patterns of family physicians in practice-based research networks: a report from ASPN. Ambulatory Sentinel Pratice Network.

BACKGROUND: Practice-based research networks are growing and undertaking larger and more complex studies to inform the clinical practice of family physicians. We describe a study that compares clinical behaviors of physicians in the Ambulatory Sentinel Practice Network (ASPN), a large national practice-based research network, with those from the National Ambulatory Medical Care Survey (NAMCS). METHODS: A survey, replicating NAMCS, was conducted among 129 family physician members of ASPN. Nested logistic regression was used to determine which services could predict ASPN membership after adjustment for common and easily observed patient and physician characteristics. RESULTS: Of 20 specific patient services, only 4 were predictive of membership in ASPN. Of these 4, 2 were screening or diagnostic services; ASPN physicians were 1.18 times more likely to obtain a blood pressure measurement and 0.60 times as likely to order a culture for streptococcal pharyngitis. ASPN physicians were 2.30 times more likely to provide family planning counseling and 1.66 times more likely to provide smoking cessation counseling after adjusting for patient smoking status. CONCLUSIONS: We conclude that there are minimal differences in the practice patterns of family physicians participating in a large national practice-based research network and those included in the probability sample of NAMCS. Additional work is needed to examine further those characteristics of the phenomena observed in practice-based research network research that might affect generalizability of results to the larger community of practicing family physicians.

Does managed care restrictiveness affect the perceived quality of primary care? A report from ASPN. Ambulatory Sentinel Practice Network.

BACKGROUND: The competitive managed care marketplace is causing increased restrictiveness in the structure of health plans. The effect of plan restrictiveness on the delivery of primary care is unknown. Our purpose was to examine the association of the organizational and financial restrictiveness of managed care plans with important elements of primary care, the patient-clinician relationship, and patient satisfaction. METHODS: We conducted a cross-sectional study of 15 member practices of the Ambulatory Sentinel Practice Network selected to represent diverse health care markets. Each practice completed a Managed Care Survey to characterize the degree of organizational and financial restrictiveness for each individual health care plan. A total of 199 managed care plans were characterized. Then, 1475 consecutive outpatients completed a patient survey that included: the Components of Primary Care Instrument as a measure of attributes of primary care; a measure of the amount of inconvenience involved with using the health care plan; and the Medical Outcomes Study Visit Rating Form for assessing patient satisfaction. RESULTS: Clinicians' reports of inconvenience were significantly associated (P < .001) with the financial and organizational restrictiveness scores of the plan. There was no association between plan restrictiveness and patient report of multiple aspects of the delivery of primary care or patient satisfaction with the visit. CONCLUSIONS: Plan restrictiveness is associated with greater perceived hassle for clinicians but not for patients. Plan restrictiveness seems to be creating great pressures for clinicians, but is not affecting patients' reports of the quality of important attributes of primary care or satisfaction with the visit. Physicians and their staffs appear to be buffering patients from the potentially negative effects of plan restrictiveness.

The family APGAR and psychosocial problems in children: a report from ASPN and PROS.

BACKGROUND: Our study examined whether the lack of social support as measured by the Family APGAR was related to parents' and physicians' identification of child psychosocial problems and sociodemographic and symptom characteristics of the children screened. METHODS: The parents of 9626 children, ages 4 to 15 years, seen for outpatient medical visits participated in this national study. Parents completed the Family APGAR and the Pediatric Symptom Checklist (PSC), a measure of psychosocial dysfunction. Physicians rated the presence of a new or recurrent psychosocial problem in the child. RESULTS: Children from families with a lack of social support were 4.3 times as likely to receive scores indicating impairment on the PSC and 2.2 times as likely to be identified as having psychosocial problems by physician report. Families with low social support were significantly more likely to report low parental educational achievement, single parent status, and a history of mental health services for the child. Fifty percent of children from families with low social support were identified as having a psychosocial problem by either the PSC or physician rating, or both; however, only 21% of the children identified with psychosocial impairment by these two measures had scores indicating poor family functioning on the Family APGAR. CONCLUSIONS: A lack of family social support is associated with child psychosocial dysfunction as assessed by two different measures. However, the Family APGAR was not a sensitive measure of child psychosocial problems, and thus it supplements, but does not replace, information concerning the child's overall psychosocial functioning.

Insurance status and recognition of psychosocial problems. A report from the Pediatric Research in Office Settings and the Ambulatory Sentinel Practice Networks.

OBJECTIVE: To examine the effect of insurance status on clinician recognition of psychosocial problems for pediatric primary care visits. DESIGN: A cohort study of 10,250 visits by children 4 to 15 years old for nonemergent care. SETTING: Two large primary care research networks reported data from 172 primary care clinicians in office-based practice. PATIENTS: Ten thousand two hundred and fifty unique children presenting consecutively to participating physicians for nonemergent services with a parent or caregiver. MAIN OUTCOME MEASURE: Children were classified as positive for psychosocial problems if their score on the parent-reported Pediatric Symptom Checklist exceeded the standard cutoff of 28. Clinician recognition was obtained by report as a dichotomous variable. Insurance status was categorized by payor and plan structure. RESULTS: Clinicians did not recognize psychosocial problems for a substantial number of children with scores suggestive of marked psychosocial dysfunction on the Pediatric Symptom Checklist. Insurance type was not associated with rates of recognition. However, provider familiarity with patients, provider discipline, and patient demographics were associated with increased recognition of psychosocial problems. CONCLUSIONS: Differences in treatment among various insurance groups documented in prior studies are not likely to be related to varying recognition rates, but rather to availability and choices of treatment by insurers, families, and clinicians. Continuity of care was the strongest predictor of clinician recognition.

Defining primary care. Empirical analysis of the National Ambulatory Medical Care Survey.

OBJECTIVES: Efforts to contain health care costs have increased interest in defining which specialties provide primary care and in developing tools to assess the delivery of primary care services. METHODS: Using data from the 1985-1991 National Ambulatory Medical Care Surveys, the authors examined the activities of 29 physician specialty groups to determine whether the recent Institute of Medicine definition of primary care could be operationalized. Ten elements were identified that addressed comprehensiveness (first-contact care, a Herfindahl Index, previous contact for other problems, prevention, and care through the life cycle), coordination (referrals), continuity (any previous contact), and accessibility (care provided to black patients, those on Medicaid, and patients in rural areas). RESULTS: Principal component and factor analyses suggested that each element, except care through the life cycle, contributed to the construct of primary care. Principal component analysis enabled ordering of specialties according to their "primary careness," suggesting that specialties other than family/general practice, pediatrics, and internal medicine make significant contributions to primary care. Factor analysis suggested that two factors related to process and content underlie the definition of primary care and emphasize the importance of integration of services provided. This analysis provides a basis for further empirical work to develop measures of primary care performance. CONCLUSIONS: National surveys need to be modified to provide a more comprehensive assessment of primary care in the United States.

Practice-based research networks: building the infrastructure of primary care research.

Family practice and primary care are rapidly achieving prominence as the foundation of a rapidly changing health care system, driven not by systematic reform but by the rapid advance of managed care. The knowledge base to support primary care practice, however, lags far behind after decades of neglect in the headlong rush toward overspecialization. The success of biomedical research in the United States in the last 50 years is due in large part to the network of tertiary care hospitals, where the specialized care of highly selected patients supports broad programs of teaching and research. There are no comparable laboratories, however, for research on the important content areas of primary care. The emergence and success of practice-based research networks over the past decade provide an important infrastructure for careful study of the health and health care phenomena that comprise primary care. Practice-based research networks have made a great deal of progress in methods development and have begun to contribute important information to the primary care knowledge base. They continue, however, to be underfunded and underdeveloped, existing on large infusions of volunteerism by the participating physicians. The study recently completed by the Institute of Medicine's Committee on the Future of Primary Care will play a critical role in promoting widespread appreciation of the gap in the scientific base necessary to support primary care practice, the need for research in primary care, and the complementary relationship of this body of research and the more traditional biomedical research that has been so well funded.

Toward optimal laboratory use. Problems in laboratory testing in primary care.

OBJECTIVE: To examine the frequency and characteristics of problems in laboratory testing in primary care physicians's offices and their impact on health care. DESIGN: Prospective descriptive study in which participating office-based primary care clinicians reported each occurrence of any laboratory incident during a 6-month study. Each identified problem was reported on a structured data collection instrument with an open-ended description of the problem. SETTING: Primary care physicians' offices in North America. PARTICIPANTS: One hundred twenty-four primary care clinicians in 49 practices of the Ambulatory Sentinel Practice Network (ASPN). MAIN RESULTS: A total of 180 problems were reported, yielding a crude rate of 1.1 problems per 1000 patient visits. Problems involving test ordering and specimen handling were the most common (56%), while those attributable to the test analysis itself accounted for 13% of the total. In the judgment of the practice staff, 27% of the reported problems had an impact on patient care. Of the 24 cases for which the specific impact was known and reported, half of the impacts were minor and about half were significant, as judged by whether or not the diagnosis and/or treatment of the patient was measurably affected. CONCLUSIONS: Clinically apparent problems with laboratory testing in primary care were found at a rate of 1.1 problems per 1000 patient visits. Of the laboratory problems that occurred in this study, 27% were judged by the physician to have an effect on patient care.