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Biomedical subjects

K C Stange

Publications and source records attributed to K C Stange.

At least 55 records · Page 3Linked to original sources
PubMed1998

Primary care practice organization and preventive services delivery: a qualitative analysis.

BACKGROUND: Rapid developments within the health care environment have led to increased pressures for change among primary care physicians and their practices. Nevertheless, a lack of understanding of practice organization and function has limited the effectiveness of attempts to change practice behaviors. Recent attempts to increase the delivery of preventive health care services illustrate the limitations of current approaches. To assist physicians in their attempts at change, our study looked at the office as a whole system and at the competing demands within the primary care setting. METHODS: Qualitative fieldnotes were recorded by research nurses who observed 138 family physicians in 84 practices in northeast Ohio for 4 days each. These data were content-analyzed to identify features that are important for understanding how practices are organized. RESULTS: These data indicate that primary care practice is much more complex than research and transformation efforts generally acknowledge. The data identified a diverse set of features that describe how primary care practices are organized and function. These included cognitive and behavioral components of physician philosophy and style, and numerous features of the practice organization, such as office efficiency, clarity of staff roles, communication patterns among physicians and staff, and approaches to using office protocols. The data also suggest that some practices are more innovative than others and that some physicians or staff have special motivations that can support or inhibit a particular change. CONCLUSIONS: Physicians who want to change their practice, as well as those persons who want to stimulate change from the outside, need to have a more comprehensive approach than is now commonly used to assess practices that encompass a broad spectrum of variables.

Continuity of Patient Care↗
PubMed1998

The impact of recent emotional distress and diagnosis of depression or anxiety on the physician-patient encounter in family practice.

BACKGROUND: Primary care physicians are expected to identify mental health problems. Currently, it is unclear how a recent experience of emotional distress affects the physician-patient encounter and the diagnostic process. METHODS: Using the Davis Observation Code, we studied 1269 encounters between family physicians and adult patients who completed brief questionnaires after the visit. Patients were separated into three groups using self-report and billing data: those denying recent emotional distress, those reporting recent emotional distress but not receiving a mental health diagnosis, and those reporting recent emotional distress and receiving a diagnosis of anxiety or depression. RESULTS: Nineteen percent of patients reported significant emotional distress during the previous 4 weeks; 18% of these patients received a billing diagnosis of depression or anxiety. Patients not reporting emotional distress had the shortest visits (10.0 minutes); recent emotional distress was associated with significantly longer visits: 11.5 minutes for those without a diagnosis of depression or anxiety and 12.8 minutes for those with a diagnosis of depression or anxiety. The visits of patients with a diagnosis of depression or anxiety included more counseling, history-taking, and discussions of family information and substance use, and less time providing physical examination and evaluation feedback. Fewer preventive services and less chatting occurred when patients reported recent distress, regardless of diagnosis. CONCLUSIONS: Recent patient emotional distress has a powerful impact on the structure of the family practice visit, with important implications for efforts to enhance diagnosis and treatment of mental health issues. The challenge for the family physician is to recognize and treat a patient's emotional distress while continuing to fulfill competing medical demands.

Anxiety Disorders↗
PubMed1998

Opportunistic preventive services delivery. Are time limitations and patient satisfaction barriers?

BACKGROUND: The use of illness visits as opportunities to increase the delivery of preventive services has been widely recommended, but its feasibility in community practice is not known. We examined the prevalence of this opportunistic approach to providing preventive services, and the degree to which patient satisfaction and time limitation are barriers. METHODS: Consecutive patient illness visits to 138 community family physicians were directly observed. Visits by patients who received at least one preventive service recommended by the US Preventive Services Task Force were compared with visits by patients not receiving any recommended preventive services, controlling for potentially confounding patient characteristics. RESULTS: Among 3547 illness visits, preventive services were delivered during 39% of visits for chronic illness and 30% of visits for acute illness. Opportunistic health habits counseling occurred more frequently than screening or immunization. Visit satisfaction reported by 2454 patients using the Medical Outcomes Survey 9-item Visit Rating Scale was not different during illness visits with or without the delivery of preventive services. The duration of illness visits that included preventive services was an average of 2.1 minutes longer than illness visits without such interventions (95% confidence interval, 1.7-2.4). CONCLUSIONS: The delivery of preventive services during illness visits is common in community practice and is well accepted by patients. The expansion of an opportunistic approach to providing preventive services will require attention to time-efficient approaches.

Adult↗
PubMed1998

Making time for tobacco cessation counseling.

BACKGROUND: The objective of this study was to examine the incidence, targeting, and time demands of tobacco cessation advice by community family physicians. METHODS: Research nurses directly observed 2 days of outpatient visits to 138 family physicians in northeast Ohio. Smoking status was identified by patient questionnaire. Visit characteristics were determined from direct observation and billing data. Visits by smokers with and without smoking cessation advice were compared. RESULTS: The incidence of tobacco cessation advice was highest during wellness visits (55% vs 22% for illness visits; P < .001). Smokers seen for a tobacco-related chronic illness were more likely to receive advice than those seen for a chronic problem not related to tobacco (32% vs 17%; P = .05). The average duration of advice was less than 1 1/2 minutes. There were no significant differences in the duration of advice across different types of visits. CONCLUSIONS: Physicians are providing brief, targeted interventions for smoking cessation in family practices. The findings support the feasibility of implementing a brief intervention with all smokers seen during office visits.

Counseling↗
PubMed1998

The effect of a secondary patient on the family practice visit.

BACKGROUND: This study describes how the provision of care to a family member other than the identified patient affects the outpatient family practice visit. METHODS: Research nurses directly observed consecutive patient visits on 2 separate days in the offices of 138 practicing family physicians. Patient visits during which another family member's problem was addressed were identified. Differences in patient and visit characteristics, patient satisfaction, delivery of preventive services, and time use, measured with the Davis Observation Code, were compared for visits with and without the provision of care to a family member. RESULTS: Care was provided to a secondary patient during 18% of observed outpatient visits. The secondary patient was present during only half of these visits. When another family member's problem was discussed, patients were more likely to report that their expectations for the visit were met. There was no difference in patient report of satisfaction with the visit, the delivery of preventive services, or the level of billing for visits at which another family member's problem was addressed. Visits during which another family member's problem was discussed were an average of 1.3 minutes longer; with less time spent chatting, providing feedback, and conducting physical examinations, and more time spent counseling, taking history, gathering family information, and delivering preventive services. CONCLUSIONS: The provision of care to a second family member is relatively common in family practice, and affects the care of the index patient in identifiable ways. This care of another family member represents an important added value of family practice.

Adolescent↗
PubMed1998

Physician employment status and practice patterns.

BACKGROUND: Many physicians today are employed by another physician, group, hospital, HMO, or other organization. However, the differences in the characteristics, practice patterns, and patient outcomes of self-employed and employed physicians are not well understood. METHODS: The practices of 108 community family physicians in northeast Ohio were assessed using a multimethod cross-sectional design. Physician characteristics were assessed by questionnaire. Direct observation of 3536 consecutive patient visits was used to measure time use and the delivery of preventive services recommended by the US Preventive Services Task Force. Patient satisfaction was assessed with the Medical Outcomes Study (MOS) 9-item Visit Rating Form. RESULTS: Employed physicians were more likely to be female, in group practice, work fewer hours, and see fewer patients. Job satisfaction was similar between the two groups, but employed physicians reported greater satisfaction with leisure and family time. Employed physicians spent more time per patient visit, scheduled a larger percentage of well-care visits, and were more likely to refer to specialists. Employed physicians also spent a greater proportion of their patients' visit time performing history-taking and eliciting family information, and a lesser proportion of time on physical examination, planning treatment, providing health education, and chatting. Recommended screening and health habits counseling preventive services were more likely to be delivered by employed physicians. Patient satisfaction was similar for the two groups. CONCLUSIONS: Primary care physician characteristics and practice patterns differ by employment status. The consequences of the trend toward a largely employed physician workforce as reported in this study should be carefully considered.

Adult↗
PubMed1998

Billing for physician services: a comparison of actual billing with CPT codes assigned by direct observation.

BACKGROUND: Little is known about the accuracy of family physicians' use of the Current procedural Terminology (CPT) coding scheme for office visits, despite increased administrative oversight of Medicare billing practices. In addition, the patient and visit characteristics that are associated with over- and undercoding are not well understood. METHODS: This study compared coding for evaluation and management (E&M) services billed for 3791 visits to 138 family physicians with the codes assigned by trained research nurses using direct observation. We calculated the degree to which the codes for E&M were concordant with the observer-assigned codes. Analysis of variance and logistic regression were used to examine the association of visit and patient characteristics with discordance between billed and observer-assigned CPT codes. RESULTS: Billing codes were concordant for 55% of encounters. Discordance was evenly distributed between under- and overcoding. Concordance of billed and observed codes was greatest for patients with indemnity insurance. Undercoding increased with longer visit length and a smaller percentage of the visit spent planning treatment. Overcoding was more common during visits with a greater percentage of time spent chatting, planning treatment, and delivering preventive services. CONCLUSIONS: Family physicians are generally accurate in their billing procedures. The findings on patient and visit characteristics associated with over- or undercoding may be used by practicing clinicians to enhance the accuracy of their coding and billing procedures.

Adult↗
PubMed1998

Patient satisfaction with time spent with their physician.

BACKGROUND: We examined the variables related to patient satisfaction with the time spent with their family physician during the office visit. METHODS: Research nurses directly observed consecutive patient visits to 138 family physicians in 84 practices. Analyses examined sequential models of the association of patient and physician characteristics, visit type and length, and time use during visits, with patients' satisfaction with the amount of time spent with their physician. RESULTS: Among 2315 visit by adult patients returning questionnaires, patient satisfaction with the time spent with their physician was high and strongly linked to longer visits (P < 001). After controlling for visit duration, greater patient satisfaction with time spent was associated with older patient age, white race, better perceived health status, visits for well care, and visits with a greater proportion of the visit spent chatting. The physician's discussion of test results or findings from the physical examination was associated with greater satisfaction with time spent for visits longer than 15 minutes, but with less satisfaction with time spent for shorter visits. CONCLUSIONS: Physicians can enhance patient satisfaction with the amount of time spent during an office visit by spending a small proportion of time chatting about nonmedical topics, and by allowing sufficient time for exchange with the patient is feedback is necessary.

Adult↗
PubMed1998

Patient and visit characteristics associated with opportunistic preventive services delivery.

BACKGROUND: This study's purpose was to identify patient and visit characteristics associated with the use of illness visits as opportunities for the delivery of preventive services and to determine if time is allocated differently during illness visits that make use of these opportunities. METHODS: Research nurses directly observed the delivery of preventive services during consecutive patient visits on 2 separate days in the offices of 138 family physicians. Data on patient eligibility for preventive services were collected by medical record review. Time use during patient visits was categorized using the Davis Observation Code (DOC). Patient characteristics, visit characteristics, and time use were compared during illness visits in which at least one service recommended by the US Preventive Services Task Force was delivered to eligible patients, compared with illness visits during which no recommended preventive services were delivered. RESULTS: Preventive services were delivered during 32% of 3547 illness visits. Adults, overweight patients, those who smoke or drink alcohol, new patients, and patients with fewer visits in the past year were more likely to receive preventive services. Patient request was also associated with increased delivery of preventive services. The presence of another family member, visits for an acute illness, and the prescription of a drug were associated with a decreased likelihood of a patient's receiving preventive services. When preventive services were delivered during illness visits, less time was spent on chatting, procedures, and physical examination, and more time was spent on history-taking. CONCLUSIONS: Family physicians take greater advantage of opportunities for the delivery of preventive services during the illness visits of high-risk patients. The results of our study suggest strategies that could be used to expand the opportunistic delivery of preventive services to other patients and types of visits.

Adolescent↗
PubMed1997

Direct observation of community-based ambulatory encounters involving medical students.

CONTEXT: The current shift of predoctoral medical education from inpatient tertiary settings to community-based, ambulatory practice has raised questions about the effect of the medical student on the process of patient care. OBJECTIVE: To determine how the presence of a medical student during the ambulatory medical encounter affects the use of clinical time and patient satisfaction. DESIGN: Cross-sectional, multimethod study using direct observation of ambulatory care by research-trained nurses. SETTING: A total of 16 community-based family practice offices accepting family practice clerkship students. PATIENTS: A total of 452 outpatient visits with and without student involvement. MAIN OUTCOME MEASURES: Clinical time use as measured by the Davis Observation Code; patient satisfaction was assessed with the Medical Outcomes Study 9-item visit rating scale. RESULTS: When students were involved, physicians spent more time discussing visit expectations (P=.03) and less time in history taking (P=.007), providing assessment (P=.01), and answering questions (P=.04). Despite these differences, patients were equally satisfied with explanations received, and there was no change in the rank order of the 5 most commonly observed physician behaviors. There was no difference in time spent in treatment planning, physical examination, health education, or social chatting. The physician spent equal time with the patient with (10.3 minutes) and without (9.9 minutes, P=.6) student involvement. There was no decrease in patient satisfaction when students were involved. Physicians were more likely to discuss another family member's problems when a student was present (P=.001). Students were directed to care for minority patients at a disproportionate rate (P=.001), controlling for confounding variables. CONCLUSIONS: Medical student involvement alters the content but not the duration of the ambulatory medical encounter. Application of validated measures indicate that students did not impair patient satisfaction or hinder the physicians' ability to ensure that patient expectations for the visit were met.

Ambulatory Care↗
PubMed1997

The impact of insurance type and forced discontinuity on the delivery of primary care.

BACKGROUND: The effect of managed care on important attributes of primary care is poorly understood. Of particular concern is the potential for annual bidding on managed care contracts, which may cause forced discontinuity of care. We examined the effect of insurance type and insurance-mandated disruption in continuity of care on the quality of primary care. METHODS: A cross-sectional study design was used to examine 1839 patient visits to 138 community-based primary care physicians. The quality of primary care delivery was measured with the Components of Primary Care Instrument, a patient-reported indicator of physician knowledge of the patient, interpersonal communication, coordination of care, continuity of care, and patients' preference to see their regular physician. RESULTS: No significant differences in any of the five indicators of primary care quality were found between patients with independent provider association/preferred provider organization (IPA/PPO) and fee-for-service insurance. Patients with IPA/PPO health insurance were four times as likely as patients with fee-for-service insurance to report a forced change in their primary care physician (P < or = .01). Individuals forced to change their physician because of changes in their health care insurance scored significantly lower on all five indicators of primary care quality (P < or = .01). CONCLUSIONS: The quality of primary care appears to be less dependent on the payment system than on the maintenance of the patient-physician relationship. Forced disruption of continuity of care is detrimental to patient receipt of quality primary care, and is a potential negative consequence of annual bidding for managed care contracts.

Adult↗
PubMed1997

Missed opportunities for prevention: smoking cessation counseling and the competing demands of practice.

BACKGROUND: Smoking cessation advice is an effective intervention for the control of tobacco use. The objective of this study was to assess and describe the rates of smoking status assessment and smoking cessation advice provided by physicians during ambulatory office visits with respect to physician specialty, type of visit, and number of problems addressed at the visit. METHODS: We used a cross-sectional survey of patient visits to the offices of nonfederally employed, office-based physicians participating in the 1992 National Ambulatory Medical Care Survey (n = 1558). RESULTS: Physicians reported knowing the smoking status of their patients in 66% of outpatient visits. The rate of assessment was similar for generalists and specialists. Cardiologists and generalists, except for pediatricians, showed discernible rates of smoking cessation advice (medians ranging from 14% to 50%), whereas obstetrician/gynecologists and other specialists had negligible rates. For tobacco-related visits, generalists and specialists had comparable rates of cessation advice to identified smokers. For non-tobacco-related visits, generalists had higher rates than specialists (22% vs 10%; P < .001). CONCLUSIONS: Although a substantial majority of smokers are reportedly identified by physicians during ambulatory visits, a large number of identified smokers are not receiving smoking cessation counseling. Patients seen by generalists are more likely to receive smoking cessation advice. Physicians appear to prioritize smoking cessation advice based on diagnosis at the time of the visit.

Adolescent↗
PubMed1996

A comparison of US and Canadian family physician attitudes toward their respective health-care systems.

OBJECTIVES: To examine how family physicians in the United States and Canada evaluate their respective health-care systems. METHODS: The study design was a cross-sectional survey of 300 randomly selected US family physicians and 300 Canadian family physicians. Outcome measures included: attitudes about professional satisfaction and views on health-care delivery and government involvement in health care. RESULTS: Sixty-one percent of the US sample and 67% of the Canadian sample responded. After performing factor and discriminant analyses, we were able to identify nine characteristics differentiating the two groups of physicians. United States physicians were more likely to be older, male, working in rural areas, conservative in their political thinking, and satisfied with their ability to obtain diagnostic tests. United States physicians viewed the health-care system as being in need of fundamental changes, less likely to advocate a central role for government, and more likely to report that litigation concerns influence their clinical decisions. CONCLUSIONS: This study documents differences between Canadian and US family physicians, and suggests that US family physicians might not easily accept a Canadian-style health-care system. Policy makers implementing health-care system changes should be cognizant of the attitudes of physicians that might determine their acceptance or rejection of such changes.

Adult↗
PubMed1996

Primary care research: barriers and opportunities.

A paucity of relevant scientific evidence limits the ability of the primary care disciplines to practice evidence-based medicine and to advocate for health care policy. Significant barriers to primary care research still exist, including difficulties in translating practice-based wisdom into methodologically sound research, the lack of a critical mass of researchers, a poorly developed research culture, and competing demands faced by investigators. In addition, the categorical nature of most available research funding is unfavorable for the generalist focus of primary care research. Efforts to advance primary care research will require support from health care organizations, dedicated federal and state funding sources, and foundations. In addition, there is a need to provide sophisticated methodological training for a small cadre of primary care researchers while increasing opportunities for a large number of clinicians to participate in research. Opportunities for transdisciplinary collaboration need to be increased, including the creation of primary care research centers. The development of a scientific basis for primary care practice will require policy advocacy, development of infrastructure, and creative and sustained individual effort.

Humans↗
PubMed1994

Dissemination of information about the US Preventive Service Task Force guidelines.

We assessed the familiarity of family physicians with the US Preventive Service Task Force guidelines and targeted groups for interventions to increase the practice of recommended preventive services. A national random sample of 480 family physicians were mailed a survey consisting of demographic items and a question regarding their level of exposure to the guidelines. The association of demographic factors with the level of exposure was assessed. Of the 263 responding physicians, 37% reported that they had not read any of the recommendations. Physicians who had read at least some of the recommendations were younger, more recently graduated from medical school, less likely to be in solo practice, more likely to be residency trained, and more likely to be white. Only year of graduation and race remained significantly associated with exposure to the guidelines in a logistic regression model. Additional dissemination efforts should focus on solo practitioners, less recent graduates, and nonwhite physicians.

Adult↗