Relative impact of patient and clinic factors on adherence to primary care preventive service guidelines: an exploratory study.

BACKGROUND: Preventive care service use is commonly compared across health plans, clinics, or individual providers, yet little is known about the influence of the clinic versus patient factors on utilization of these services. OBJECTIVES: To measure the relative influence of the facility (clinic) versus patient factors (demographic, behavioral and functional characteristics) on patients' utilization of mammography, Pap smears, cholesterol screening, and retinal exams for those with diabetes. RESEARCH DESIGN: Retrospective analysis, using administrative and patient survey data. SUBJECTS: Enrollees in 2 University-based clinics and a county hospital-based clinic serving a predominantly low-income population with limited access to health care. Eligibility for cervical cancer screening, screening mammography, cholesterol screening, or annual retinal exam (diabetes) was defined by age, sex, and diagnosis. MEASURES: Multivariate models, one using readily available administrative data, and another using detailed health status and behavior data gathered from a clinics-wide survey. RESULTS: Unadjusted screening rates for three of four procedures were significantly and substantially lower at the county hospital based clinic than the two University-based clinics. After adjusting for patient characteristics, utilization of three screening services at the county hospital remained significantly below the University-based clinics (Odds Ratios [95% CI]: mammogram 0.15 [0.06-0.35]; Pap smear 0.32 [0.21-0.50]; cholesterol 0.19 [0.09-0.38]; diabetes retinal exam10.68 [0.93-3.01]). The models with detailed survey data performed only marginally better than the models using only administrative data. CONCLUSIONS: Patient characteristics were much less important than the clinic for predicting whether patients received primary care preventive services. Our results suggest that case mix adjustment is unlikely to explain away discrepancies in performance between clinics or provider groups.

Use of a questionnaire to improve occupational and environmental history taking in primary care physicians.

New patient charts were reviewed before and after the introduction of a self-administered questionnaire, designed to elicit occupational and environmental (OE) information from patients. The Occupational Health Risk Assessment questionnaire (OHRA) was expected to prompt primary care physicians to make further inquiries into OE health issues. Chart reviews determined the amount and type of information detailed in the primary care physicians' notes. Twenty-three percent of completed OHRAs indicated a job-related health problem. Despite a high prevalence of self-reported work-related symptoms and exposures, the mean number of notations regarding OE exposures was less than one item per patient chart. A comparison of mean OE notations per chart before versus after introduction of the OHRA indicated a decline in notations after introduction of the OHRA (1.03 vs 0.72, P = 0.02). We detail the type of OE issues that patients presented to a primary care practice and the resulting information contained in primary care providers' notes. Suggestions are made to improve a self-administered patient questionnaire to better diagnose, prioritize, and formulate treatment plans related to OE issues.

A controlled time-series trial of clinical reminders: using computerized firm systems to make quality improvement research a routine part of mainstream practice.

OBJECTIVE: To explore the feasibility of conducting unobtrusive interventional research in community practice settings by integrating firm-system techniques with time-series analysis of relational-repository data. STUDY SETTING: A satellite teaching clinic divided into two similar, but geographically separated, primary care group practices called firms. One firm was selected by chance to receive the study intervention. Forty-two providers and 2,655 patients participated. STUDY DESIGN: A nonrandomized controlled trial of computer-generated preventive reminders. Net effects were determined by quantitatively combining population-level data from parallel experimental and control interrupted time series extending over two-month baseline and intervention periods. DATA COLLECTION: Mean rates at which mammography, colorectal cancer screening, and cholesterol testing were performed on patients due to receive each maneuver at clinic visits were the trial's outcome measures. PRINCIPAL FINDINGS: Mammography performance increased on the experimental firm by 154 percent (0.24 versus 0.61, p = .03). No effect on fecal occult blood testing was observed. Cholesterol ordering decreased on both the experimental (0.18 versus 0.1 1, p = .02) and control firms (0.13 versus 0.07, p = .03) coincident with national guidelines retreating from recommending screening for young adults. A traditional uncontrolled interrupted time-series design would have incorrectly attributed the experimental-firm decrease to the introduction of reminders. The combined analysis properly indicated that no net prompting effect had occurred, as the difference between firms in cholesterol testing remained stochastically stable over time (0.05 versus 0.04, p = .75). A logistic-regression analysis applied to individual-level data produced equivalent findings. The trial incurred no supplementary data collection costs. CONCLUSIONS: The apparent validity and practicability of our reminder implementation study should encourage others to develop computerized firm systems capable of conducting controlled time-series trials.

Rural hospitals' experience with the National Practitioner Data Bank.

OBJECTIVES: This study examined hospital administrators' experiences with the National Practitioner Data Bank. METHODS: One hundred forty-nine rural hospital administrators completed questionnaires assessing their perceptions of the data bank. RESULTS: Nearly 90% of respondents rated the data bank as an important source of information for credentialing. Three percent indicated it had directly affected privileging decisions; 43% and 34%, respectively, believed the costs exceeded or equaled the benefits. Twenty percent reported changes that could decrease disciplinary action reports to the data bank. CONCLUSIONS: While the National Practitioner Data Bank is an important source of information to rural hospitals, it may, affect few credentialing decisions and motivate behavioral changes that could have a paradoxical effect on quality assurance.

A comparison of self-report and chart audit in studying resident physician assessment of cardiac risk factors.

OBJECTIVE: To examine the relationship between resident physicians' perceptions of their preventive cardiology practices and a chart audit assessment of their documented services. DESIGN: A criterion standard comparison of two methods used to assess resident physicians' practices: self-report and chart audit. SETTING: Physician ambulatory care in a residency program. PATIENTS AND OTHER PARTICIPANTS: Coronary artery disease (CAD) risk factor assessment was evaluated by self-report for 72 resident physicians and by chart audit of randomly selected records of 544 of their patients who did not have CAD or a debilitating chronic disease during a one-year period. INTERVENTION: Measurements of the residents' perceived CAD risk factor assessment practice by self-report, and chart audit assessments of their recorded care. MAIN OUTCOME: The relationship between self-reported and chart audit assessments of CAD risk factors. RESULTS: Chart audit assessment of CAD risk factor management was highly significantly (p < 0.01) lower than self-reported behaviors for evaluation of cigarette smoking, diet, physical activity, stress, plasma cholesterol, blood pressure, and body weight/obesity. CONCLUSIONS: Three different interpretations of these findings are apparent. 1) Physician self-report is a poor tool for the measurement of clinical behavior, and therefore research of physician behavior should not rely solely on self-reported data; 2) physicians' chart recording of their clinical practice is insufficient to reflect actual care; or 3) neither is an accurate measure of actual practice.

Appropriate screening tests in infants, children, and adolescents.

Specific recommendations and the rationale for targeted screening procedures in infants, children, and adolescents have been reviewed. The utility of many tests is uncertain, often because of poor characterization of the disease or problem targeted. For example, the optimum time for treatment and whether treatment results in long-term benefits frequently are unknown. The development of recommendations based on evidence-based approaches promises to rationalize the delivery of preventive health care services in the pediatric population.

Smoking cessation counseling among hospitalized smokers.

The purposes of this study were (1) to describe how much smoking cessation counseling patients receive in a hospital with a nonsmoking policy and (2) to describe the attitudes of these smokers toward the nonsmoking policy. Forty-three (48%) of 89 eligible smokers hospitalized during a one-month period were surveyed by mail. Sixty-eight percent reported receiving, during hospitalization or at the time of discharge, at least one of nine counseling procedures related to smoking cessation. Forty-eight percent reported more than one counseling procedure. Less than 15% received information about symptoms of nicotine withdrawal, means of abstaining during hospitalization, means of permanently quitting, or medications for nicotine withdrawal symptoms during hospitalization. None of the patients had smoking cessation included in plans for future care upon hospital discharge. Only 24% strongly disagreed with the hospital's nonsmoking policy. We conclude that the mere institution of a nonsmoking hospital policy does not ensure that hospitalized smokers are adequately counseled regarding smoking cessation or that this counseling will be considered in discharge planning.

Physicians' attitudes toward preventive care services: a seven-year prospective cohort study.

We report results of a seven-year prospective cohort study of physicians' attitudes about and intentions to provide 27 preventive care services in their future practices. Respondents in the cohort were surveyed three times: first, during orientation to medical school; second, during their third year of medical school; and finally, following completion of their third-year of residency training. The majority of preventive care services were viewed as more important to clinical practice in primary care than in non-primary care specialties. Positive attitudes toward preventive care services generally persisted among both primary and non-primary care physicians. Respondents expressed only fair to medium levels of confidence in the ability of physicians in their specialty areas to provide any of the preventive services examined. Respondents reported low levels of confidence in the ability of primary care physicians to provide nutritional counseling, though they ranked it as important. Respondents were fairly or moderately confident in the ability of primary care physicians to provide counseling about smoking cessation, health, AIDS education, and substance abuse. Participants ranked smoking cessation counseling, health counseling, AIDS education, cancer detection education, and substance abuse counseling and education as very important. In general, physicians were less likely to plan on providing preventive services than they were to expect their residency programs to prepare most or all to provide the services. Findings document the need to prepare physicians better to provide preventive services.

The Health of the Public Program at the University of Washington: a new role for academic medical centers.

The University of Washington Health of the Public Program has convened a consortium composed of the region's academic medical center, the two largest managed care plans in Washington, and representatives of the state's major private and public purchasers of health care. The consortium's purpose is to test the feasibility of collaboratively collecting cross-system data, assessing variations in practice, and implementing site-specific interventions to improve the management of common illnesses and encourage preventive care. Changes under way in the ambulatory training environment and in the undergraduate curriculum as a result of the consortium's initial efforts are described. In today's climate of cost consciousness and concerns about quality, academic medical centers can play an important role in helping to improve community-wide outcomes of care.

Oral contraceptive use and coronary risk factors in women.

The relationship between oral contraceptive use and other coronary artery disease risk factors was examined in 215 nonsmoking women grouped as never, current, or previous users. Current oral contraceptive users had higher triglyceride levels (p less than or equal to 0.001) than other groups, higher systolic blood pressure, and lower plasma HDL-cholesterol levels (p less than or equal to 0.05) than previous users. The effect of oral contraceptive use on plasma triglyceride values persists on multivariate regression analysis independently of age, body mass index, dietary sodium and cholesterol intake, cigarette smoking, and level of physical activity. Oral contraceptive use also has an independent relationship to the plasma total cholesterol/HDL- cholesterol ratio. These findings indicate that oral contraceptive use is adversely associated with plasma lipid and lipoprotein values.

Assessment and counseling of coronary risk factors by family practice residents.

A study was undertaken to determine (1) the likelihood that patients seen for episodic health care in a family medical center have been assessed and counseled for coronary heart disease (CHD) risk factors, and (2) the likelihood that patients having an identified risk factor have been assessed and counseled regarding other CHD risk factors. One thousand five hundred twenty-eight medical records were randomly selected from all visits occurring over two periods in 1986 and 1987 to 122 residents in an eight-site family medicine residency network. Patients with cardiovascular disease and those younger than 20 or older than 65 years of age were excluded. Assessments were made of (1) smoking history, blood pressure, weight, physical activity, and dietary content during the previous 12 months; (2) family history of cardiovascular disease during the previous 12 months and in the initial patient history; (3) and blood cholesterol during the prior 5 years. Risk-factor counseling practices were examined for the previous 12 months. Blood pressure was assessed in 96% of patients, smoking in 40%, cholesterol in 26%, and family history in 52%. Ninety-six percent of hypertensive patients were counseled for hypertension, but only 45% of smokers and 20% of patients with hypercholesterolemia were counseled for those risk factors. Of patients having a given risk factor, assessment for any other risk factor occurred in fewer than 60% of cases. Patients having a documented positive family history were only slightly more likely than other patients to be assessed for additional risk factors. There is continued need for enhancing coronary risk-factor assessment and counseling by resident physicians.(ABSTRACT TRUNCATED AT 250 WORDS)

Preventive cardiology education and practice in residency training: residents' attitudes, perceptions, and practices.

This paper presents results from two studies of primary care residency programs. Study I was a survey of preventive cardiology attitudes and practice-related intentions of internal medicine and family medicine residents from throughout the United States. Study II consisted of an examination of family medicine residents' perceptions regarding preventive practices and a series of 1,528 medical record reviews of their related assessment and counseling practices. The specific aims were to examine residents' perceptions about their residency programs and to determine the percentages of patients who were assessed for and, if necessary, counseled for coronary heart disease prevention. Results indicated that internal and family medicine residents believe that they should be prepared by their residency training to offer these services and that their residencies were preparing most of them to do so. While they report that they intend to assess and counsel patients in these areas, they do not seem to be doing so. The medical record reviews strongly indicated that they are not providing these services at the recommended levels, especially for assessment of and counseling for smoking and blood cholesterol levels.

A survey of fourth-year medical students' decisions regarding family practice as a career.

With a decline in the proportion of medical students pursuing family practice careers, it is necessary to better understand the factors influencing their career decisions. The Fishbein model of attitude formation was used as a framework for developing a questionnaire to measure students' attitudes toward a career in family practice and the social support students perceived they had for that career. The questionnaire was administered to fourth-year-medical students a short time before residency match day. Both the attitude and social support scales had excellent psychometric characteristics. The usefulness of these scales in discriminating between career choices of family practice and other clinical careers was tested. The social support scale did not discriminate well, whereas the attitude scale discriminated quite well. The students who chose careers in family practice differed from students who chose other careers in 14 of 19 values about characteristics of family practice but differed from them in only two of 19 beliefs about family practice. The implications for advising medical students about careers in family practice are discussed.

Curricular influences on preventive-care attitudes.

Attitudes are one of the most important outcomes of medical education, but little is known about curricular influences on specific attitudes. This study examined changes in attitudes toward 20 preventive-care services in a cohort of 175 medical students. Specifically, a cohort of medical students was followed over a 30-month interval that spanned the period from medical school entry through the first 6 months of clinical clerkships. Perceived importance, as well as student confidence in the ability of primary-care physicians to provide 20 preventive-care services, was examined. Importance ratings for preventive-care services remained stable, while levels of confidence in the ability of physicians to provide the services increased. Implications of the results are discussed in relation to the possibilities for emphasizing disease prevention content in medical education.

Preventive care attitudes of medical students.

Presently developing attitudes of future physicians towards preventive medicine will likely provide either a major impetus for or barriers to the inclusion of preventive medicine content in medical school curricula and in other formats of physician education. In turn, attitudes about preventive care and its role in medical practice will continue to have a large influence on how much disease prevention and health promotion emphasis physicians provide in their practices. Consequently, it becomes important to study how medical students' attitudes evolve during the process of medical education. Furthermore, to the extent that we can better understand how desired attitudes can be developed and nurtured, the practice of preventive medicine may become more purposeful. Beginning and third-year medical students were surveyed with a 100-item questionnaire designed to assess their attitudes regarding: the relative importance of 20 specific preventive services to the practice of medicine and the adequacy of preclinical coursework for preparing them to offer preventive care in medical practice. The confidence of third year students' in the ability of primary care physicians to provide these specific services was also assessed. Preventive care service areas about which third-year students expressed high confidence in the ability of physicians to provide were: immunizations, health screening physicals, blood pressure control, cancer detection education, family planning, health counseling/education, and sexually transmitted disease prevention. Services that students had low confidence in the ability of physicians to provide were: smoking cessation, nutrition counseling/education and weight reduction.(ABSTRACT TRUNCATED AT 250 WORDS)