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INTRODUCTION: The We Run This City (WRTC) Youth Marathon Program is a community-supported, school-based fitness program designed to increase physical activity in a large, urban school district by engaging middle school youth to train 12 to 14 weeks to run or walk 1.2 miles, 6.2 miles, or 13.1 miles of the Rite Aid Cleveland Marathon. The objective of our study was to evaluate the effect of the intervention on adolescent health. METHODS: We assessed changes in obesity, health, and fitness, measured before training and postintervention, among 1,419 sixth- to eighth-grade students participating in WRTC for the first time, with particular interest in the program's effect on overweight (85th-94th body mass index percentile) or obese (≥95th percentile) students. We collected data from 2009 through 2012, and analyzed it in 2016 and 2017. Outcomes of interest were body mass index (BMI), waist-to-hip ratio (WHR), elevated blood pressure, and fitness levels evaluated by using the Progressive Aerobic Cardiovascular Endurance Run (PACER) test and the sit-to-stand test. RESULTS: We saw significant improvements overall in fitness and blood pressure. Controlling for demographics, program event, and training dosage, BMI percentile increased among normal weight participants and decreased among overweight and obese participants (P < .001). WHR increased among obese participants, whereas reductions in blood pressure among those with elevated blood pressure were associated with higher amounts of training and lower baseline BMI. CONCLUSION: Even small amounts of regular physical activity can affect the health and fitness of urban youths. School-community partnerships offer a promising approach to increasing physical activity by supporting schools and making a school-based activity inclusive, fun, and connected to the broader fitness community.
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Serviços de Saúde Comunitária , Aptidão Física , Serviços de Saúde Escolar , Adolescente , Exercício Físico , Feminino , Humanos , Masculino , Condicionamento Físico Humano , Corrida , CaminhadaRESUMO
BACKGROUND: Nourishing Beginnings is an integrated referral and service delivery model supporting Medicaid-eligible pregnant individuals by providing increased nutritional food access throughout pregnancy up to three months postpartum, through community health workers (CHW), who simultaneously address and provide support for social service needs of the client. METHODS: To study the impact of possible interventions on food security, the program includes two distinct interventions each paired with traditional CHW services, nutrition educational materials, and provision of basic essential cooking tools. Interventions consist of either bi-weekly home food delivery from the local food bank or bi-weekly financial assistance with healthy food access navigation. The study population consists of 160 pregnant individuals (18 or older,<22 weeks pregnant; 80 per intervention arm) who were referred to a countywide Pathways Community HUB (HUB), a community-based care coordination network that uses an evidence-based model to connect at-risk individuals to resources that address medical, social, economic, and behavioral health needs. Key data collection occurs at baseline, eight weeks after intervention begins, near delivery (36-38 weeks gestation), and three months postpartum. Intervention groups are compared to each other as well as against HUB historical controls and a concurrent matched sample from local Medicaid data. CONCLUSION: The goal of Nourishing Beginnings is to improve long-term health outcomes (i.e., maternal and infant) both directly and mediated through a set of proximal outcomes, including prenatal care, food security, diet and nutrition, reported race discrimination and psychosocial factors including depression, stress, healthy eating self-efficacy, and social support. Clinical Trials #: NCT05341960.
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CONTEXT: An important phase of HIV prevention research is replicating successful interventions with different groups and in different settings. METHODS: Be Proud! Be Responsible!, a successful intervention originally targeting black urban males and carried out in nonschool settings, was presented in health classes at urban and suburban schools with diverse student bodies. A group-randomized intervention study, which included 1,357 ninth and 10th graders from 10 paired schools in a Midwestern metropolitan area, was conducted in 2000-2002. Half the schools received the intervention, and half received a general health promotion program. Students' reports of their sexual behavior and selected cognitive mediators were analyzed immediately following the programs and four and 12 months later. RESULTS: Compared with students who received the control curriculum, students exposed to the intervention reported significantly greater knowledge of HIV, other STDs and condoms; greater confidence in their ability to control sexual impulses, to use condoms and to negotiate the use of condoms; and stronger intentions to use condoms. Stratified analyses revealed that the strongest intervention impacts were on knowledge and efficacy among males and students attending suburban schools. The intervention had no impact on sexual initiation, frequency of intercourse or condom use. CONCLUSIONS: Schools are a logical and viable setting for the dissemination and acquisition of information about HIV, including prevention strategies. However, the behavioral impact of an intervention may not be easily transferable when the program is taught outside a carefully controlled, nonschool setting.
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Comportamento do Adolescente/psicologia , Infecções por HIV/psicologia , Conhecimentos, Atitudes e Prática em Saúde , Serviços de Saúde Escolar/estatística & dados numéricos , Educação Sexual/métodos , Adolescente , Preservativos/estatística & dados numéricos , Feminino , Humanos , Masculino , Meio-Oeste dos Estados Unidos/epidemiologia , Educação de Pacientes como Assunto , Sexo Seguro/estatística & dados numéricos , Estudantes/estatística & dados numéricosRESUMO
RATIONALE, AIMS, AND OBJECTIVES: This study examines the degree to which a "Hawthorne effect" alters outpatient-visit content. METHODS: Trained research nurses directly observed 4454 visits to 138 family physicians. Multiple data sources were used to examine the Hawthorne effect including differences in medical record documentation for observed visits and the prior visit by the same patient, time use during visits on the first versus the second observation day of each physician, and report by the patient, physician, and observer of the effect of observation. RESULTS: Visits on the first versus the second observation day were longer by an average of 1 minute (P < .001); there were time-use differences for 4 of 20 behaviour categories evaluated. No effect of the observer on the interaction was reported by 74% of patients and 55% of physicians. Most of those that reported an affect indicated it was slight. Patients with non-White race, lower-educational level, and poorer health were more likely to report being affected by the observer. CONCLUSIONS: In a study that was designed to minimize the Hawthorne effect, the presence of an observer had little effect on most patient-physician visits but appeared to at least slightly effect a subgroup of vulnerable patients.
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Medicina de Família e Comunidade/estatística & dados numéricos , Pesquisa sobre Serviços de Saúde/métodos , Observação , Visita a Consultório Médico/estatística & dados numéricos , Feminino , Pesquisa sobre Serviços de Saúde/normas , Nível de Saúde , Humanos , Masculino , Anamnese , Prontuários Médicos/estatística & dados numéricos , Educação de Pacientes como Assunto , Relações Médico-Paciente , Qualidade da Assistência à Saúde , Fatores Socioeconômicos , Fatores de TempoRESUMO
BACKGROUND: Despite the large potential of dietary changes to reduce morbidity and mortality, the frequency, time spent, and factors associated with nutrition counseling in primary care are not well studied. METHODS: In a cross-sectional study of 84 family physician practices in northeast Ohio, nutrition counseling was measured by direct observation on 2 days for all consecutive ambulatory visits. The frequency, time spent, and patient and visit characteristics associated with nutrition counseling were determined. RESULTS: Among 138 family physicians, only 6% included nutrition counseling in the majority (>50%) of patient encounters. Among 3475 consecutive outpatient visits in adults, nutrition counseling occurred in 24% of all patient visits, 17% of visits for acute illnesses, 30% of chronic illness visits, and 41% of well-care visits. The average time spent on nutrition counseling was 55 seconds, ranging from <20 seconds to >6 minutes. Nutrition counseling occurred in 45% of visits for diabetes, 25% of visits for cardiovascular disease, 31% of visits for hypertension, 26% of prenatal visits, and 33% of visits by obese patients (body mass index >30). Nutrition counseling was more likely to occur during visits by patients who were older or had diabetes mellitus, during visits for well care or chronic illness, and during longer visits. CONCLUSION: Despite considerable variability from physician to physician, nutrition counseling occurs in approximately one fourth of all office visits to family physicians. The observed efforts by family physicians to focus nutrition counseling on high-risk patients may increase its impact.
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Serviços de Saúde Comunitária/organização & administração , Aconselhamento , Fenômenos Fisiológicos da Nutrição , Educação de Pacientes como Assunto , Serviços Preventivos de Saúde/organização & administração , Atenção Primária à Saúde/organização & administração , Adulto , Idoso , Idoso de 80 Anos ou mais , Distribuição de Qui-Quadrado , Estudos Transversais , Feminino , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Ohio , Padrões de Prática Médica/estatística & dados numéricosRESUMO
BACKGROUND: The long-term effect of most interventions has not been studied. Changes due to interventions to improve patient care may revert to baseline after the intervention stimulus ends. This analysis reports the 24-month follow-up of a practice-tailored intervention to increase preventive service delivery rates. DESIGN: Group randomized clinical trial with 24-month follow-up of intervention sites. SETTING/PARTICIPANTS: Seventy-seven community family practices in northeast Ohio. INTERVENTION: Practice-individualized facilitation of implementation of tools and approaches. MAIN OUTCOME MEASURES: Summary scores of health habit counseling, screening, and immunization services recommended by the U.S. Preventive Services Task Force that were up to date for consecutive patients during randomly selected chart review days. RESULTS: Previously reported increases in global preventive service delivery rates, health habit counseling, and screening rates at 12 months were sustained after 24 months. CONCLUSIONS: A practice-individualized approach can result in sustainable increases in rates of preventive service delivery, even 1 year after the outside intervention stimulus ends. Tailoring of approaches to the unique characteristics of each practice may result in institutionalization of changes.
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Medicina de Família e Comunidade/organização & administração , Serviços Preventivos de Saúde/estatística & dados numéricos , Aconselhamento , Seguimentos , Humanos , OhioRESUMO
BACKGROUND: Despite increasing recognition of women's health needs, little is known about how primary care physicians spend time with women. Therefore, we examined differences in time use and preventive service delivery during outpatient visits by male and female patients. METHODS: As part of a multimethod study of 138 family physicians, 3384 outpatient visits by adults were directly observed, medical records were reviewed, and patient surveys were performed. Time use was assessed by the Davis Observation Code, which classifies every 15 seconds into 20 behavioral categories. Receipt of health habit counseling recommended by the U.S. Preventive Services Task Force was assessed by direct observation, and eligibility was determined by chart review. Logistic regression and multivariate analysis of variance (ANOVA) were used to compare time use and preventive service delivery in visits by women vs. men. RESULTS: Sixty-four percent of adult visits were from women. Women reported poorer physical health, had higher rates of anxiety (12.5% vs. 7.4% in men), and depression (21.9% vs. 8.4% in men), a higher percent of visits for well care (10.2% vs. 8.8% in men), and more drugs prescribed (64.8% vs. 61% in men) and raised more emotional issues than men (14.7% vs. 7.5%). After controlling for visit and patients characteristics, visits by women had a higher percent of time spent on physical examination, structuring the intervention, patient questions, screening, and emotional counseling. Visits by men involved a higher percent of time spent on procedures and health behavior counseling. More eligible men than women received exercise, diet, and substance abuse counseling. Patients of female physicians exhibited gender differences in only one category of how time was spent (substance abuse), whereas among patients of male physicians, gender differences were noted in 10 of the 20 categories. CONCLUSIONS: Outpatient visits by women differ from those of men in ways that reflect women's unique healthcare needs but also raise concern about unequal delivery of health habit counseling for diet and exercise.
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Atitude do Pessoal de Saúde , Aconselhamento/estatística & dados numéricos , Visita a Consultório Médico , Relações Médico-Paciente , Padrões de Prática Médica , Atenção Primária à Saúde , Adulto , Idoso , Análise de Variância , Estudos Transversais , Medicina de Família e Comunidade/estatística & dados numéricos , Feminino , Pesquisa sobre Serviços de Saúde , Humanos , Masculino , Pessoa de Meia-Idade , Visita a Consultório Médico/estatística & dados numéricos , Ohio , Satisfação do Paciente , Médicas/estatística & dados numéricos , Padrões de Prática Médica/estatística & dados numéricos , Serviços Preventivos de Saúde/estatística & dados numéricos , Atenção Primária à Saúde/estatística & dados numéricos , Fatores Sexuais , Fatores de TempoRESUMO
OBJECTIVES: To determine whether family physicians provide different ambulatory care to patients with health insurance from managed care organization (MCO) versus fee-for-service (FFS) plans. STUDY DESIGN: Multimethod cross-sectional observational study. PATIENTS AND METHODS: A total of 4454 patients made office visits to 138 family physicians in northeastern Ohio. Direct observation with the Davis Observation Code and a structured checklist were used to assess the process of care. Patient satisfaction was measured with the Medical Outcomes Study 9-Item Visit Rating Form. RESULTS: Among 1588 patients with MCO insurance and 876 with FFS insurance, no differences were noted in the number of visits per year, length of visits, percentage of visits for well care, or the percentage of visits in which medicines were prescribed in analyses controlling for patient mix. Visits by patients with MCO insurance were more likely to involve referrals to another physician than visits by patients with FFS insurance. Patient satisfaction and time use during visits were comparable for the 2 groups. CONCLUSIONS: Managed care insurance appears to increase involvement of the primary care provider in the referral process. However, in a healthcare market with moderate managed care penetration in which the same physicians see patients with different types of insurance, the process of care is affected little by type of insurance coverage.
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Assistência Ambulatorial/organização & administração , Medicina de Família e Comunidade/organização & administração , Planos de Pagamento por Serviço Prestado , Programas de Assistência Gerenciada , Adulto , Estudos Transversais , Feminino , Pesquisa sobre Serviços de Saúde , Humanos , Masculino , Visita a Consultório Médico , Ohio , Satisfação do Paciente/estatística & dados numéricos , Avaliação de Processos em Cuidados de Saúde , Revisão da Utilização de Recursos de SaúdeRESUMO
The effect of a rapidly changing healthcare system on personnel turnover in community family practices has not been analyzed. We describe physician and staff turnover and examine its association with practice characteristics and patient outcomes. A cross-sectional evaluation of length of employment of 150 physicians and 762 staff in 77 community family practices in northeast Ohio was conducted. Research nurses collected data using practice genograms, key informant interviews, staff lists, practice environment checklists, medical record reviews, and patient questionnaires. The association of physician and staff turnover with practice characteristics, patient satisfaction, and preventive service data was tested. During a 2-year period, practices averaged a 53% turnover rate of staff. The mean length of duration of work at the current practice location was 9.1 years for physicians and 4.1 years for staff. Longevity varied by position, with a mean of 3.4 years for business employees, 4.0 years for clinical employees, and 7.8 years for office managers. Network-affiliated practices experienced higher turnover than did independent practices. Physician longevity was associated with a practice focus on managing chronic illness, keeping on schedule, and responding to insurers' requests. No association was found between turnover and patient satisfaction or preventive service delivery rates. Personnel turnover is pervasive in community primary care practices and is associated with employee role, practice network affiliation, and practice focus. The potentially disruptive effect of personnel turnover on practice functioning, finances, and longitudinal relationships with patients deserves further study despite the reassuring lack of association with patient satisfaction and preventive service delivery rates.
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Enfermeiras e Enfermeiros , Reorganização de Recursos Humanos , Médicos , Atenção Primária à Saúde/organização & administração , Humanos , Ohio , Satisfação do Paciente , Estudos RetrospectivosRESUMO
Significant disparities in health care based on patient socioeconomic status have been documented. The extent to which physician behavior accounts for these differences is not known. We examined the impact of patient socioeconomic status, measured by years of education, on physician behavior assessed by direct observation of office visits, chart audits, and patient reports among 138 family physicians in 84 practices. Outcomes included time use measured with the Davis Observation Code, delivery of preventive services recommended by the US Preventive Services Task Force, satisfaction assessed with the MOS 9-item Visit Rating Scale, and delivery of attributes of primary care measured by the Components of Primary Care Index. After controlling for patient characteristics among 2538 visits by adult patients who returned questionnaires, a high school education or less was associated with slightly greater proportion of time spent on physical examination and providing nutrition counseling, and less time on patient questions, assessing patient health knowledge, negotiation, and exercise counseling. This indicates that physicians adopt a more directive style with less educated patients. Screening tests were provided at lower rates among less educated patients, but there were no differences in rates of health habit counseling or immunization services delivered and no differences in delivery of patient-reported components of primary care. Less educated patients had similar overall visit satisfaction, but were slightly less likely to have their expectations met. These show that patients' education has relatively small, but potentially important, effects on the outpatient delivery of primary care.
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Pacientes/estatística & dados numéricos , Relações Médico-Paciente , Padrões de Prática Médica/estatística & dados numéricos , Estudos Transversais , Atenção à Saúde , Escolaridade , Medicina de Família e Comunidade , Humanos , Modelos Logísticos , Visita a Consultório Médico , Serviços Preventivos de Saúde/estatística & dados numéricos , Fatores SocioeconômicosRESUMO
Faced with a rapidly changing healthcare environment, primary care practices often have to change how they practice medicine. Yet change is difficult, and the process by which practice improvement can be understood and facilitated has not been well elucidated. Therefore, we developed a model of practice change using data from a quality improvement intervention that was successful in creating a sustainable practice improvement. A multidisciplinary team evaluated data from the Study To Enhance Prevention by Understanding Practice (STEP-UP), a randomized clinical trial conducted to improve the delivery of evidence-based preventive services in 79 northeastern Ohio practices. The team conducted comparative case-study analyses of high- and low-improvement practices to identify variables that are critical to the change process and to create a conceptual model for the change. The model depicts the critical elements for understanding and guiding practice change and emphasizes the importance of these elements' evolving interrelationships. These elements are (1) motivation of key stakeholders to achieve the target for change; (2) instrumental, personal, and interactive resources for change; (3) motivators outside the practice, including the larger healthcare environment and community; and (4) opportunities for change--that is, how key stakeholders understand the change options. Change is influenced by the complex interaction of factors inside and outside the practice. Interventions that are based on understanding the four key elements and their interrelationships can yield sustainable quality improvements in primary care practice.
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Equipes de Administração Institucional , Modelos Organizacionais , Serviços Preventivos de Saúde/provisão & distribuição , Atenção Primária à Saúde/normas , Gestão da Qualidade Total/organização & administração , Feminino , Pesquisa sobre Serviços de Saúde , Humanos , Masculino , Motivação , Ohio , Cultura Organizacional , Inovação Organizacional , Atenção Primária à Saúde/organização & administração , Avaliação de Programas e Projetos de Saúde , Gestão da Qualidade Total/métodosRESUMO
Advances in the surgical approach to thoracic aortic aneurysm repairs have led to the increasing use of one-lung ventilation. Today's practice of cardiothoracic and vascular anesthesia requires a clear understanding of the techniques available for lung separation and the technical skills necessary to employ them. In this article, we discuss and evaluate the options for one-lung ventilation in thoracic aortic aneurysm repair with regard to preoperative, intraoperative, and postoperative management.
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Aneurisma da Aorta Torácica/cirurgia , Ventilação Monopulmonar/métodos , Procedimentos Cirúrgicos Vasculares/métodos , Humanos , Cuidados Intraoperatórios/métodos , Masculino , Pessoa de Meia-Idade , Cuidados Pós-Operatórios/métodos , Cuidados Pré-Operatórios/métodosRESUMO
BACKGROUND: Medical records are important for facilitating the process and quality of care. However, little is known about their current state in primary care practices. This article describes features of medical record systems in diverse practices and examines their association with preventive service delivery rates. METHODS: Medical records were reviewed from a consecutive sample of outpatients seen by 198 family physicians in 79 community-based practices in Northeast Ohio. The physicians were participants in a clinical trial designed to increase preventive service delivery. Research nurses performed baseline medical record reviews and used ethnographic field notes and a practice environment checklist to provide global assessments of features of medical records. RESULTS: In 79 practices, 3462 medical records were reviewed. Medical records were rated as highly easy to use in 52% of practices; outpatient visit notes were dictated in 54%. Nine percent of practices grouped individual charts by family. Patient notes were computerized in 1% of practices, although several practices had previously tried and abandoned computerized systems. Flow sheets for immunization, screening, and counseling were present on 71%, 63%, and 16% of charts and were used on 34%, 33%, and 3% of charts, respectively. The presence and use of flow sheets were associated with higher preventive service delivery rates. CONCLUSION: Medical record organization, completeness, and use vary widely, and computerized records remain rare. The association of flow sheet presence and use with preventive service delivery rates shows the potential importance of medical records for enhancing the process and outcome of patient care.
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Medicina de Família e Comunidade , Sistemas Computadorizados de Registros Médicos , Serviços Preventivos de Saúde/estatística & dados numéricos , Atenção Primária à Saúde/estatística & dados numéricos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Criança , Pré-Escolar , Estudos Transversais , Documentação , Feminino , Humanos , Lactente , Recém-Nascido , Masculino , Pessoa de Meia-Idade , OhioRESUMO
PURPOSE: We undertook a study to examine the impact of experiences shared between patient and physician and the value patients place on continuity of care. METHODS: Data on 4,454 patients collected in The Direct Observation of Primary Care (DOPC) study conducted between October 1994 and August 1995 were analyzed to assess the value patients place on continuity, length of patient-physician relationship, and experiences shared between patient and physician. RESULTS: A significant interaction was yielded between duration of relationship and experiences shared between patient and physician (P = .03). For all lengths of relationship with the physician, the value that patients have for continuity increased when patients indicated experiences shared with the physician. For patients who did not report experiences shared with the physician, the longer the relationship, the greater the value placed on continuity. CONCLUSIONS: The results of this study point to the importance of the experiences shared between patients and physicians and the value that patients place on continuity with their regular physician.
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Continuidade da Assistência ao Paciente , Medicina de Família e Comunidade/normas , Satisfação do Paciente , Relações Médico-Paciente , Análise de Variância , Humanos , Estados UnidosRESUMO
Previous research on geographic variations in health care contains limited information regarding inner-city medical practice compared with suburban and rural settings. Our main objective was to compare patient characteristics and the process of providing medical care among family practices in inner-city, suburban, and rural locations. A cross-sectional multimethod study was conducted emphasizing direct observation of outpatient visits by trained research nurses involving 4,454 consecutive patients presenting for outpatient care to 138 family physicians during 2 days of observation at 84 community family practices in northeast Ohio. Time use during office visits was assessed with the Davis Observation Code; satisfaction was measured with the Medical Outcomes Study nine-item Visit Rating Scale; delivery of preventive services was as recommended by the US Preventive Services Task Force; and patient-reported domains of primary care were assessed with the Components of Primary Care Instrument. Results show that inner-city patients had more chronic medical problems, more emotional problems, more problems evaluated per visit, higher rates of health habit counseling, and longer and more frequent office visits. Rural patients were older, more likely to be established with the same physician, and had higher rates of satisfaction and patient-reported physician knowledge of the patient. Suburban patients were younger, had fewer chronic medical problems, and took fewer medications chronically. Inner-city family physicians in northeast Ohio appear to see a more challenging patient population than their rural and suburban counterparts and have more complex outpatient office visits. These findings have implications for health system organization along with the reimbursement and recruitment of physicians in medically underserved inner-city areas.
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Medicina de Família e Comunidade/organização & administração , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Serviços de Saúde Rural/estatística & dados numéricos , Serviços de Saúde Suburbana/estatística & dados numéricos , Serviços Urbanos de Saúde/estatística & dados numéricos , Adulto , Estudos Transversais , Medicina de Família e Comunidade/estatística & dados numéricos , Feminino , Pesquisa sobre Serviços de Saúde , Humanos , Masculino , Pessoa de Meia-Idade , Visita a Consultório Médico/estatística & dados numéricos , OhioRESUMO
BACKGROUND: We know little about the activities that occur during asthma-related visits with primary care physicians. A better understanding of how time is spent during visits for asthma may facilitate the design of programs to enhance asthma disease management. OBJECTIVE: To describe the content of asthma visits made to family physicians. METHODS: Research nurses directly observed consecutive outpatient visits during two separate days in the offices of 138 community family physicians. Time was classified into 20 different behavioral categories using the Davis Observation Code, and compared for visits for asthma, visits for other chronic conditions, and visits for non-asthma-related acute illnesses during 3035 visits by patients of all ages. RESULTS: Visits for asthma shared several characteristics with visits for other chronic conditions but were longer than visits for other chronic illnesses or for acute illness. Asthma visits were distinguished from both acute care and other chronic care visits by a greater percentage of time spent discussing patient compliance, evaluating patient knowledge, and providing smoking assessment and cessation advice. CONCLUSIONS: Visits for asthma are structured differently than acute care visits and specifically address issues important to asthma self-management. Future quality improvement initiatives should recognize, affirm, and enhance many current behaviors by family physicians, while working to expand specific areas of care that still fall short of asthma care guidelines.
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Asma/psicologia , Asma/terapia , Serviços de Saúde Comunitária/estatística & dados numéricos , Medicina de Família e Comunidade/organização & administração , Visita a Consultório Médico , Adulto , Doença Crônica , Estudos Transversais , Gerenciamento Clínico , Feminino , Conhecimentos, Atitudes e Prática em Saúde , Humanos , Internato e Residência , Masculino , Pessoa de Meia-Idade , Ohio , Cooperação do Paciente , Relações Médico-PacienteRESUMO
OBJECTIVE: To identify differences in time use during acute and chronic care visits. POPULATION: Patients coming to outpatient offices of physician members of a practice-based research network in Ohio. MEASURES: Direct observation and coding of physician activities during acute and chronic care visits. RESULTS: Time use varied by visit type with more time spent on compliance assessment, negotiation, and nutrition advice during chronic care visits. Acute care visits included more time for procedures, physical examination, feedback on test results and health education. CONCLUSION: Physicians structure their use of time to fit the differing goals of acute and chronic care visits.
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Medicina de Família e Comunidade/organização & administração , Visita a Consultório Médico/estatística & dados numéricos , Estudos de Tempo e Movimento , Doença Aguda/terapia , Agendamento de Consultas , Doença Crônica/terapia , Estudos Transversais , Medicina de Família e Comunidade/estatística & dados numéricos , Feminino , Pesquisa sobre Serviços de Saúde , Humanos , Modelos Logísticos , Masculino , Observação , OhioRESUMO
OBJECTIVE: To determine whether outpatient visits by elders seeing community family physicians differ in length or content from visits by younger patients; socioemotional preferences predict visit content; and satisfaction correlates with visit content differentially across age. METHODS: In a multimethod cross-sectional study of 84 community family practices in northeastern Ohio, 3453 adult patient visits with 138 community family physicians were observed; 2362 of these patients completed self-report questionnaires. Three age groups were compared: 18 to 64, 65 to 74, and over 74 years. Length and content of the physician-patient encounter was determined using the Davis Observation Code (DOC); satisfaction was assessed using the MOS 9-item Visit Rating Scale. RESULTS: Controlling for reason for visit and demographics, visit length averaged 10.7 minutes for each group. Visit content differed significantly on 13 of 20 DOC codes between one of the older groups and the younger group; in 4 instances, content varied between the 2 older groups. Although visit content varied as predicted by socioemotional theory, no consistent patterns of association between visit content and satisfaction emerged. DISCUSSION: Older patient visits differ from those of younger patients as might be predicted by socioemotional selectivity theory; however, there was little association of visit content with patient satisfaction.
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Medicina Comunitária , Medicina de Família e Comunidade , Relações Médico-Paciente , Atenção Primária à Saúde , Adulto , Idoso , Idoso de 80 Anos ou mais , Estudos Transversais , Feminino , Comportamentos Relacionados com a Saúde , Promoção da Saúde , Humanos , Masculino , Pessoa de Meia-Idade , OhioRESUMO
BACKGROUND: Inconsistent findings on the value of continuity of care can stem from variability in its importance to different subsets of patients. We therefore examined the association among patient and visit characteristics and extent to which the patient valued continuity of care (PVC). We hypothesized that continuity would be more important to patients who are older, sicker, and female, who have established a relationship with their physician, and whose visit addresses more complex problems. METHODS: A study of 4,454 consecutive outpatient visits to 138 community-based family physicians used a 3-item measure (alpha = 0.67) of PVC. The patient's report of (1) the adequacy of primary care for the visit and (2) satisfaction with the physician on that visit was assessed with multiple measures. Analyses examined the associations among PVC and patient-reported satisfaction with the physician and adequacy of the visit. RESULTS: Extremes of age, female sex, less education, Medicare and Medicaid insurance, number of chronic conditions and medications, number of visits to the practice, and worse self-reported health status were associated with higher value placed on continuity (P < .001 for all except sex, where P = .015). Patients who value continuity and did not see a regular physician rated adequacy of the visit lower (for 7 attributes of the visit) than those seeing their own physician. Satisfaction with the physician for the visit was greatest among patients who value continuity and saw their regular physician. CONCLUSIONS: Continuity of physician care is associated with more positive assessments of the visit and appears to be particularly important for more vulnerable patients. Health care systems and primary care practices should devote additional effort to maintaining a continuity relationship with these vulnerable patients.