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Biomedical subjects

Christopher B Forrest

Publications and source records attributed to Christopher B Forrest.

At least 37 records · Page 2Linked to original sources
PubMed2003

Referral of children to specialists in the United States and the United kingdom.

OBJECTIVE: To compare the rates and patterns of children's specialty referrals in the United States (US) and the United Kingdom (UK). DESIGN: Retrospective cohort analysis of health care claims/encounter data obtained in 1996 (US) and 1997 (UK). SETTING: Children in the US were selected from 5 managed health plans that used primary care physicians as gatekeepers: 2 health maintenance organizations and 3 point-of-service plans. Point-of-service plans allow patient self-referral at increased out-of-pocket costs. In the UK, the General Practice Research Database provided data from 211 general practices. PARTICIPANTS: Children, from birth to the age of 17 years, with no cost sharing for physician services in the US (n = 135,092) and who were registered with general practitioners, all of whom authorize patients' access to specialty care, in the UK (n = 221,312). MAIN OUTCOME MEASURE: Annual percentage of children referred to a specialist. RESULTS: Across the 5 US plans, 18.6% to 28.8% of the patients per year were referred vs 8.7% of the patients per year in the UK sample. Referral rates were not significantly different between a health maintenance organization and a point-of-service plan administered by a single insurer. Compared with patients in the UK sample, those in the US plans were 1.9 times more commonly referred to medical specialists and 3.2 times more commonly referred to surgical specialists. There was considerable cross-national variation in specialty-specific referral rates for children with selected conditions. CONCLUSIONS: Children in US managed care plans are between 2 and 3 times as likely to be referred to specialists compared with counterparts in the UK. Although these referral rate differences are substantial, our findings cannot be construed to mean that the US referral rates are too high or that the UK rates are too low. The greater supply of specialists and higher expectations for direct access to specialty care in the US, compared with the UK, are likely explanations for these differences in children's specialty referral rates.

Adolescent↗
PubMed2003

Which enrollees bypass their gatekeepers in a point-of-service plan?

BACKGROUND AND OBJECTIVES: Like Health Maintenance Organizations, point-of-service (POS) health plans use primary care gatekeepers, and they permit self-referral to specialists at increased costs to the enrollee. The main objective of this study was to contrast patients who self-referred with those referred by their primary care physician. RESEARCH DESIGN: We conducted a cross-sectional telephone survey of 606 recent users of specialists in a large Midwestern POS health plan; response rate was 65%. We compared 148 enrollees who self-referred with 458 who had a physician referral. RESULTS: Self-referral was most common among those with a long-term relationship with a specialist (odds ratio [OR] = 2.08) and those dissatisfied with their primary care physician (OR = 3.65), and was rare among those with a long-standing relationship with a primary care physician (OR = 0.46). Most self-referred enrollees (68%) thought paying the additional cost for self-referral was worthwhile, and they were more dissatisfied with the quality and variety of the plan's specialist network. CONCLUSIONS: Continuity with a single physician influences how patients access specialty care. Expanding the panel of specialists in-network and encouraging long-term relationships with primary care physicians are likely to limit self-referral in a POS plan.

Adult↗
PubMed2003

Managed health plan effects on the specialty referral process: results from the Ambulatory Sentinel Practice Network referral study.

OBJECTIVES: The specialty referral process is one of the chief targets of managed care constraints on ambulatory medical decision-making. This study examines the influence of gatekeeping arrangements and capitated primary care physician (PCP) payment on the specialty referral process in primary care settings. RESEARCH DESIGN: Primary care practice-based study of referred and nonreferred office visits. SUBJECTS: The study comprised 14,709 visits made by privately insured, nonelderly patients who were seen by 139 primary care physicians in 80 practices located in 31 states. MEASURES: Visits were grouped by health plan type: gatekeeping with capitated PCP payment; gatekeeping with fee-for-service PCP payment; no gatekeeping. Dependent measures included the proportion of visits referred, characteristics of referrals, and physician coordination activities. RESULTS: The percentages of office visits resulting in a referral were similar between the two gatekeeping groups and higher than the no gatekeeping group. Patients in plans with capitated PCP payment were more likely to be referred for discretionary indications than those in nongatekeeping plans (15.5% v 9.9%, P < 0.05). The frequency of referring physician coordination activities did not vary by health plan type. The proportion of patients in gatekeeping health plans within a practice was directly related to employing staff as referral coordinators, allowing nurses to refer without physician consultation, and permitting patients to request referrals by leaving recorded telephone messages. CONCLUSION: The specialty referral process for privately insured nonelderly patients enrolled in managed health plans is generally similar, regardless of the presence of gatekeeping arrangements and capitated PCP payment. An increase in the number of discretionary referrals among patients in plans with capitated PCP payment provides support for exploring strategies that encourage PCPs to manage in their entirety conditions that straddle the boundaries between primary and specialty care. In response to increasing numbers of patients enrolled in managed health plans with gatekeeping arrangements, physicians appear to modify the structure of their practices to facilitate access to and coordination of referrals.

Capitation Fee↗
PubMed2003

Outcomes research in pediatric settings: recent trends and future directions.

OBJECTIVE: Pediatric outcomes research examines the effects of health care delivered in everyday medical settings on the health of children and adolescents. It is an area of inquiry in its nascent stages of development. METHODS: We conducted a systematic literature review that covered articles published during the 6-year interval 1994-1999 and in 39 peer-reviewed journals chosen for their likelihood of containing child health services research. This article summarizes the article abstraction, reviews the literature, describes recent trends, and makes recommendations for future work. RESULTS: In the sample of journals that we examined, the number of pediatric outcomes research articles doubled between 1994 and 1999. Hospitals and primary care practices were the most common service sectors, accounting for more than half of the articles. Common clinical categories included neonatal conditions, asthma, psychosocial problems, and injuries. Approximately 1 in 5 studies included multistate or national samples; 1 in 10 used a randomized controlled trial study design. Remarkably few studies examined the health effects of preventive, diagnostic, long-term management, or curative services delivered to children and adolescents. CONCLUSIONS: Outcomes research in pediatric settings is a rapidly growing area of inquiry that is acquiring breadth but has achieved little depth in any single content area. Much work needs to be done to inform decision making regarding the optimal ways to finance, organize, and deliver child health care services. To improve the evidence base of pediatric health care, more effectiveness research is needed to evaluate the overall and relative effects of services delivered to children and adolescents in everyday settings.

Adolescent↗
PubMed2003

Vulnerability and the patient-practitioner relationship: the roles of gatekeeping and primary care performance.

OBJECTIVES: We examined whether patients' perceptions of their relationships with primary care practitioners (PCPs) vary by vulnerability status and assessed the extent to which gatekeeping arrangements and primary care performance moderate potential disparities. METHODS: We used the nationally representative 1996-1997 Community Tracking Study Household Survey as our data source. RESULTS: Whites reported better patient-practitioner relationships than minorities. Requirements that patients select a PCP and obtain referral authorization neither reduced nor exacerbated racial disparities in the patient-practitioner relationship. On the other hand, access to and continuity with a PCP substantively reduced disparities, especially for the most vulnerable group. CONCLUSIONS: Enhancing primary care performance may reduce some of the barriers to care experienced by vulnerable populations, thereby improving patients' relationships with their PCPs.

Adult↗
PubMed2003

Primary care attributes and care for depression among low-income African American women.

OBJECTIVES: We examined the association between attributes of primary care providers and care for depression, from a patients' perspective, among a sample of predominantly low-income African American women. METHODS: Computer-assisted telephone interviews were conducted among a population-based sample of 1202 women residing in Washington, DC. RESULTS: Respondents whose primary care physicians provided more comprehensive medical services were more likely to be asked about and treated for depressive symptoms than women whose providers were less medically comprehensive. Women who rated their providers as having more respect for them also were more likely to be asked about and treated for depression. CONCLUSIONS: More comprehensive primary care delivery and a physician-patient relationship focused on mutual respect are associated with greater rates of physician inquiry about and treatment for depression among vulnerable women.

Adult↗
PubMed2002

Comparing apples with apples in clinical populations: applications of the adjusted Clinical Group System in British Columbia.

This article reviews the Adjusted Clinical Group Case-Mix System and describes how it is being applied in the management of physician services in British Columbia. Developed in the United States for management and research, adjusted clinical groups are used to measure the illness burden and health service needs of individuals and, when aggregated, of populations, by grouping the range of conditions coded on physician claims and hospital care records over a defined time period, typically one year. In Canadian and United States settings, adjusted clinical groups are up to five times more predictive of ambulatory resource use than are age and sex groups alone. The article describes how adjusted clinical groups are being applied to adjust capitation payments for physician groups in British Columbia's Primary Care Demonstration Project and profiles of physician practice activity.

Ambulatory Care↗
PubMed2002

Managed care, primary care, and the patient-practitioner relationship.

OBJECTIVES: This study examines how specific attributes of managed health plans influence patients' relationships with their primary care practitioners (PCPs) and determines whether these effects are mediated by access to, continuity with, or perceived choice of PCPs. DESIGN, SETTING, PATIENTS: The data source was the nationally representative 1996/97 Community Tracking Study Household Survey (cumulative response rate 65%). The study population (N = 19,415) was composed of 18- to 64-year-old adults whose most recent visit in the past 12 months was made to their primary care delivery site. MAIN OUTCOME MEASURE: Patients' ratings of their interpersonal relationships with their PCPs as measured by a 7-item scale. RESULTS: Gatekeeping arrangements that require patients to select a primary care physician or obtain authorization for specialty referrals were associated with lower ratings of the patient-PCP relationship. Health plan use of a provider network had no effect on the patient-PCP scale score. Although there were no significant differences across any insurance payer categories, uninsured adults rated their relationships with PCPs as significantly poorer than did their insured counterparts. Shorter office waits, having a specific clinician at the primary care site, better perceived choice of PCPs, and a longer duration of relationship with the primary care practitioner were associated with higher ratings of the patient-PCP relationship. Perceived choice of primary care practitioners, but not access to or continuity with PCPs, attenuated some of the negative effects of gatekeeping arrangements on patients' relationships with their primary care practitioners. CONCLUSIONS: Managed health plans that loosen restrictions on provider choice, relax gatekeeping arrangements, or promote access to and continuity with PCPs, are likely to experience higher patient satisfaction with their primary care practitioner relationships. Lack of health insurance impedes the development of patients' relationships with their primary care practitioners.

Adolescent↗
PubMed2002

Beyond the examination room: primary care performance and the patient-physician relationship for low-income women.

OBJECTIVE: To assess whether primary care performance of low-income women's primary care delivery sites is associated with the strength of their relationships with their physicians. DESIGN: Random-digit-dial and targeted household telephone survey of a population-based sample. SETTING: Washington, D.C. census tracts with > or =30% of households below 200% of federal poverty threshold. PARTICIPANTS: Women over age 40 (N=1,205), 82% of whom were African American. MEASUREMENTS AND MAIN RESULTS: The response rate was 85%. Primary care performance was assessed using women's ratings of their systems' accessibility (organizational, geographic, and financial), continuity, comprehensiveness, and coordination. Respondents' ratings of trust in their physicians, communication with their physicians, and compassion shown by their physicians were used to operationalize the patient-physician relationship. Controlling for population and insurance characteristics, 4 primary care features were positively associated with women's trust in and communication with their physicians: continuity with a single clinician, organizational accessibility of the practice, comprehensive care, and coordination of specialty care services. Better organizational access, but not geographic or financial access, was associated with greater levels of trust, compassion, and communication (odds ratios [ORs], 3.2, 7.4, and 6.9, respectively; P < or =.01). Women who rated highest their doctor's ability to take care of all of their health care needs (highest level of comprehensiveness) had 11 times the odds of trusting their physician (P < or =.01) and 6 times the odds of finding their physicians compassionate and communicative (P < or =.01), compared to those with the lowest level of comprehensiveness. CONCLUSIONS: Primary care delivery sites organized to be more accessible, to link patients with the same clinician for their visits, to provide for all of a woman's health care needs, and to coordinate specialty care services are associated with stronger relationships between low-income women and their physicians. Primary care systems that fail to emphasize these features of primary care may jeopardize the clinician-patient relationship and indirectly the quality of care and health outcomes.

Adult↗
PubMed2002

Adherence of low-income women to cancer screening recommendations.

BACKGROUND: African-American and low-income women have lower rates of cancer screening and higher rates of late-stage disease than do their counterparts. OBJECTIVE: To examine the effects of primary care, health insurance, and HMO participation on adherence to regular breast, cervical, and colorectal cancer screening. DESIGN: Random-digit-dial and targeted household telephone survey of a population-based sample. SETTING: Washington, D.C. census tracts with > or =30% of households below 200% of federal poverty threshold. PARTICIPANTS: Included in the survey were 1,205 women over age 40, 82% of whom were African American. MAIN OUTCOME MEASURES: Adherence was defined as reported receipt of the last 2 screening tests within recommended intervals for age. RESULTS: The survey completion rate was 85%. Overall, 75% of respondents were adherent to regular Pap smears, 66% to clinical breast exams, 65% to mammography, and 29% to fecal occult blood test recommendations. Continuity with a single primary care practitioner, comprehensive service delivery, and higher patient satisfaction with the relationships with primary care practitioners were associated with higher adherence across the 4 screening tests, after considering other factors. Coordination of care also was associated with screening adherence for women age 65 and over, but not for the younger women. Compared with counterparts in non-HMO plans, women enrolled in health maintenance organizations were also more likely to be adherent to regular screening (e.g., Pap, odds ratio [OR] 1.89, 95% confidence interval [CI] 1.11 to 3.17; clinical breast exam, OR 2.04, 95% CI 1.21 to 3.44; mammogram, OR 1.95, 95% CI 1.15 to 3.31; fecal occult blood test, OR 1.70, 95% CI 1.01 to 2.83.) CONCLUSIONS: Organizing healthcare services to promote continuity with a specific primary care clinician, a comprehensive array of services available at the primary care delivery site, coordination among providers, and better patient-practitioner relationships are likely to improve inner-city, low-income women's adherence to cancer screening recommendations.

Adult↗
PubMed2002

Family physicians' referral decisions: results from the ASPN referral study.

OBJECTIVE: To examine family physicians' referral decisions, which we conceptualized as having 2 phases: whether to refer followed by to whom to refer. STUDY DESIGN: Prospective cohort study. POPULATION: All visits (N = 34,519) and new referrals (N = 2534) occurring during 15 consecutive business days in the offices of 141 family physicians in 87 practices located in 31 states. OUTCOMES MEASURED: Rates of referral, reasons for referral, practitioners referred to, health problems prompting referral, and reasons for selecting particular specialists. RESULTS: Approximately 1 in 20 (5.1%) office visits led to referral. Although 68% of referrals were made by physicians during office visits, 18% were made by physicians during telephone conversations with patients, 11% by office staff with input from the physician, and 3% by staff without physician input. Physicians endorsed a mean of 1.8 reasons for making a referral. They sought specialists' advice on either diagnosis or treatment for 52.1% of referrals and asked the specialist to direct medical management for 25.9% and surgical management for 37.8%. Patient request was one reason for 13.6% of referrals. Fifty conditions accounted for 76% of all referrals. Surgical specialists were sent the largest share of referrals (45.4%), followed by medical specialists (31.0%), nonphysician clinicians (12.1%), obstetrician-gynecologists (4.6%), mental health professionals (4.2%), other practitioners (2.0%), and generalists (0.8%). Physicians recommended a specific practitioner to the patient for most (86.2%) referrals. Personal knowledge of the specialist was the most important reason for selecting a specific specialist. CONCLUSIONS: Referrals are commonly made during encounters other than office visits, such as telephone conversations or staff-patient interactions, in primary care practice. Training in the referral process should ensure that family physicians obtain the skills necessary to expand their scope of practice, when appropriate; determine when and why a patient should be referred; and identify the type of practitioner to whom the patient should be sent.

Decision Making↗
PubMedDate not supplied

The mismatch between urban women's preferences for and experiences with primary care.

Socioeconomic disparities in women's primary care experiences have been described previously. To better understand whether these disparities reflect personal preferences for primary care, rather than insurance or other access barriers, we conducted a telephone survey of a community-based sample of 1,205 women in Washington, DC. The study found that women of lower socioeconomic status had poorer primary care experiences compared with higher income counterparts, despite similarly high preferences for primary care. The poorer primary care experiences of lower socioeconomic status women were attenuated by better access to primary care. Differences in primary care attainment are not solely a matter of personal preferences; rather, they appear to be more strongly related to barriers to obtaining care.

Adult↗
PubMedDate not supplied

Primary care physician specialty referral decision making: patient, physician, and health care system determinants.

PURPOSE: To examine the effects of patient, physician, and health care system characteristics on primary care physicians' (PCPs') specialty referral decision making. METHODS: Physicians (n=142) and their practices (n=83) located in 30 states completed background questionnaires and collected survey data for all patient visits (n=34,069) made during 15 consecutive workdays. The authors modeled the occurrence of any specialty referral, which occurred during 5.2% of visits, as a function of patient, physician, and health care system structural characteristics. A subanalysis was done to examine determinants of referrals made for discretionary indications (17% of referrals), operationalized as problems commonly managed by PCPs, high level of diagnostic and therapeutic certainty, low urgency for specialist involvement, and cognitive assistance only requested from the specialist. RESULTS: Patient characteristics had the largest effects in the any-referral model. Other variables associated with an increased risk of referral included PCPs with less tolerance of uncertainty, larger practice size, health plans with gate-keeping arrangements, and practices with high levels of managed care. The risk of a referral being made for discretionary reasons was increased by capitated primary care payment, internal medicine specialty of the PCP, high concentration of specialists in the community, and higher levels of managed care in the practice. CONCLUSIONS: PCPs' referral decisions are influenced by a complex mix of patient, physician, and health care system structural characteristics. Factors associated with more discretionary referrals may lower PCPs' thresholds for referring problems that could have been managed in their entirety within primary care settings.

Adult↗
PubMedDate not supplied

Specialty referrals made during telephone conversations with parents: a study from the pediatric research in office settings network.

OBJECTIVES: To characterize variation in pediatricians' telephone referral practices, to identify differences in the types of referrals made during telephone versus office visit encounters, and to examine the impact of referring by telephone on coordination and outcomes of the referral as assessed by physicians. METHODS: We conducted a prospective study of a consecutive sample of referrals (N = 1856) made from the offices of 142 pediatricians in a national practice-based research network. During 20 consecutive practice-days, physicians completed questionnaires about patients referred during regular business hours. They used office records 3 months later to complete questionnaires about referral outcomes. RESULTS: Pediatricians made 1 telephone referral every 5 practice-days, which constituted 27.5% of all referrals they made during office hours. Pediatricians who saw more patients per day, saw more patients in gatekeeping health plans, and referred more during office visits made more telephone referrals than their counterparts. Compared with specialty referrals made during office visits, those occurring during telephone encounters were more frequently at the request of parents or because of insurance administrative guidelines. Office visit referrals were more often made for diagnostic evaluation or a surgical procedure. Referrals made during telephone conversations were less well coordinated: office staff or referring physicians scheduled fewer specialty appointments and were less likely to send information to specialists. Three months after referrals were made, specialist feedback and referring physician satisfaction with specialty care were comparable between the two groups. CONCLUSIONS: Specialty referrals made during telephone conversations with patients are a regular occurrence in pediatric practice. Changes in the health system that lead to greater demands on primary care physician productivity or more patients in gatekeeping health plans will likely increase the number of referrals made during telephone conversations with parents. Pediatricians are less likely to coordinate telephone referrals than office visit referrals. Pediatricians are frequently unaware whether or not referrals are completed.

Female↗
PubMedDate not supplied

Comorbidity: implications for the importance of primary care in 'case' management.

BACKGROUND: Although comorbidity is very common in the population, little is known about the types of health service that are used by people with comorbid conditions. METHODS: Data from claims on the nonelderly were classified by diagnosis and extent of comorbidity, using a case-mix measure known as the Johns Hopkins Adjusted Clinical Groups, to study variation in extent of comorbidity and resource utilization. Visits of patients (adults and children) with 11 conditions were classified as to whether they were to primary care physicians or to other specialists, and whether they involved the chosen condition or other conditions. RESULTS: Comorbidity varied within each diagnosis; resource use depended on the degree of comorbidity rather than the diagnosis. When stratified by degree of comorbidity, the number of visits for comorbid conditions exceeded the number of visits for the index condition in almost all comorbidity groups and for visits to both primary care physicians and to specialists. The number of visits to primary care physicians for both the index condition and for comorbid conditions almost invariably exceeded the number of visits to specialists. These patterns differed only for uncommon conditions in which specialists played a greater role in the care of the condition, but not for comorbid conditions. CONCLUSIONS: In view of the high degree of comorbidity, even in a nonelderly population, single-disease management does not appear promising as a strategy to care for patients. In contrast, the burden is on primary care physicians to provide the majority of care, not only for the target condition but for other conditions. Thus, management in the context of ongoing primary care and oriented more toward patients' overall health care needs appears to be a more promising strategy than care oriented to individual diseases. New paradigms of care that acknowledge actual patterns of comorbidities as well as the need for close coordination between generalists and specialists require support.

Adolescent↗