Biomedical subjects

K D Bertakis

Publications and source records attributed to K D Bertakis.

At least 19 recordsLinked to original sources

PubMed2001

Patient gender differences in the diagnosis of depression in primary care.

Our purpose was to explore why women are more likely than men to be diagnosed as depressed by their primary care physician. Women were found to have more depressive symptoms as self-reported on the Beck Depression Inventory (BDI). Women having high BDI scores (reflecting significant depression) were more likely than men with high BDI scores to be diagnosed by their primary care physician (p = 0.0295). Female patients made significantly more visits to the clinic than men. For both sexes, patients with greater numbers of primary care clinic visits were more likely to be diagnosed as depressed. Logistic regression revealed that gender has both a direct and indirect (through increased use) effect on the likelihood of being diagnosed as depressed. Patient BDI score, clinic use, educational level, and marital status were all significantly related to the diagnosis of depression. Controlling all other independent variables, women were 72% more likely than men to be identified as depressed, but this effect did not achieve statistical significance (p = 0.0981). In gender-specific analyses, BDI and clinic use were again significantly related to the diagnosis of depression for both sexes. However, educational and marital status predicted depression diagnosis only for women. Separated, divorced, or widowed women were almost five times as likely to be diagnosed as depressed as those who were never married, all other factors being equal. Clinic use and BDI scores were found to be important correlates of the diagnosis of depression. There was some evidence of possible gender bias in the diagnosis of depression.

Adult↗

PubMed2001

Predictors of patient referrals by primary care residents to specialty care clinics.

BACKGROUND AND OBJECTIVES: Physician referral patterns significantly impact costs, quality of care, and access to the health system. This paper examines factors predictive of patient referrals to specialists by primary care residents. METHODS: New adult patients (n=509) were randomly assigned to primary care residents at a university medical center. Patient referrals to specialists were monitored for 1 year of care. Self-reported patient health status, sociodemographic information, number of primary care visits, and physician practice style behaviors were incorporated into statistical analyses predicting specialty referrals. RESULTS: Patients who were referred to specialty care were significantly older, had poorer physical health, and saw their primary care physicians more often than patients who were not referred. Patients were most frequently referred to surgical specialty clinics. After controlling for physical health status, gender, and age, more frequent visits to a primary care resident physician who had a technically oriented style of care was associated with a greater total number of specialty clinic referrals. CONCLUSIONS: Patient variables, as well as physician practice style, have an important impact on the specialty referral process. Although the appropriateness of referrals was not evaluated, these findings have implications for health care delivery.

Adult↗

PubMed2000

The influence of patient age on primary care resident physician-patient interaction.

OBJECTIVES: To explore resident physician-patient interaction in primary care to address issues relevant to quality of care for older people. DESIGN: A sample of 509 new, adult, nonpregnant patients was assigned to the care of second- and third-year residents in primary care clinics. Care was compared for three subgroups of patients: older patients (65 years or older; n = 45), those aged 18 to 44 years (n = 320), and those aged 45 to 64 years (n = 144). SETTING: Observations were made at the family medicine and general internal medicine clinics at the University of California, Davis. MEASUREMENTS: Self-report by means of the Medical Outcomes Study Short Form-36 (MOS SF-36) was used to determine patient demographics and patient health status. Two measures of satisfaction were obtained gauging reaction to medical care in general and to the videotaped visit specifically. Videotapes were coded for content using the Davis Observation Code. RESULTS: Self-reported health status of older persons was poorer than that of younger groups as measured by the MOS SF-36. Differences in demographics were explored and then controlled, along with physical health status in subsequent analyses. Supporting prior studies, this study found that older patients had more return visits and reported higher levels of satisfaction than did younger comparison groups. Contrary to prior literature, older patients were found to have longer visits than did younger cohorts. The physician-patient interaction was significantly different in many areas between these three groups. Whereas older patients experienced more chatting in their visits, they were given less counseling, asked fewer questions, had less discussion about their families and their use of substances, were asked to change their health behavior habits less often, and were given less health education. For older patients, more of each visit was spent checking on compliance with earlier treatment and developing treatment plans. CONCLUSIONS: These results provide a new and more detailed view of how resident physician-patient interaction differs between older and younger groups and raise important issues on whether quality of care needs for this population are being adequately addressed, particularly regarding mental health issues.

Adolescent↗

PubMed2000

Gender differences in the utilization of health care services.

BACKGROUND: Studies have shown that women use more health care services than men. We used important independent variables, such as patient sociodemographics and health status, to investigate gender differences in the use and costs of these services. METHODS: New adult patients (N = 509) were randomly assigned to primary care physicians at a university medical center. Their use of health care services and associated charges were monitored for 1 year of care. Self-reported health status was measured using the Medical Outcomes Study Short Form-36 (SF-36). We controlled for health status, sociodemographic information, and primary care physician specialty in the statistical analyses. RESULTS: Women had significantly lower self-reported health status and lower mean education and income than men. Women had a significantly higher mean number of visits to their primary care clinic and diagnostic services than men. Mean charges for primary care, specialty care, emergency treatment, diagnostic services, and annual total charges were all significantly higher for women than men; however, there were no differences for mean hospitalizations or hospital charges. After controlling for health status, sociodemographics, and clinic assignment, women still had higher medical charges for all categories of charges except hospitalizations. CONCLUSIONS: Women have higher medical care service utilization and higher associated charges than men. Although the appropriateness of these differences was not determined, these findings have implications for health care.

Adult↗

PubMed1999

Comparison of primary care resident physicians' practice styles during initial and return patient visits.

New adult patients (n = 212) were randomly assigned to 58 primary care resident physicians. Physician practice styles during initial and return visits were analyzed using the Davis Observation Code. Compared with initial patient visits, return visits were shorter, but more work-intensive. Return visits displayed significantly less technically oriented behavior (including history taking, physical examination, and treatment planning) and fewer discussions regarding use of addictive substances; however, there was more emphasis on health behaviors and active involvement of patients in their own care. These physicians' practice style differences between initial and return patient visits suggest that physician-patient familiarity affects what happens during the medical interview.

Adult↗

PubMed1999

Differences between family physicians' and general internists' medical charges.

OBJECTIVES: Data from 509 primary care patients were analyzed to determine whether practice style differences between family physicians and general internists generate differential utilization of health care resources leading to differential medical charges. METHODS: New adult patients were prospectively randomized to care by family physicians and general internists. Utilization of medical care services and associated charges then were monitored for 1 year of care. RESULTS: Family practice patients had a significantly higher mean number of visits to their primary care clinic and significantly fewer emergency room visits than patients assigned to Internal Medicine. Mean charges for primary care and emergency department treatment were significantly lower for patients assigned to Family Practice than for those assigned to General Internal Medicine. There were no significant differences in charges for specialty clinic visits, hospitalizations, or diagnostic services. CONCLUSIONS: Practice style differences between family physicians and general internists were associated with differential medical charges, with family physicians generating lower charges for some aspects of care.

Adult↗

PubMed1999

Physician practice style patterns with established patients: determinants and differences between family practice and general internal medicine residents.

BACKGROUND AND OBJECTIVES: This paper examines the practice style patterns of family practice and internal medicine residents for established patient visits. METHODS: New adult patients (n = 509) were prospectively and randomly assigned to family practice or internal medicine clinics at a university medical center and followed for 1 year of care by resident physicians. Initial and return visits were videotaped, and physician practice styles were analyzed using the Davis Observation Code (DOC). RESULTS: Resident physicians' practice styles with established patients during return visits were associated with various factors, depending on the DOC cluster of behaviors studied. These factors include patient gender, age, income, physical and mental health status, level of pain, number of return visits, and physician practice style displayed during the initial encounter. Family practice return visits had a greater emphasis on preventive services and counseling, compared with internal medicine return visits. Internists spent more visit time using technically oriented behaviors. CONCLUSIONS: Patient variables, as well as baseline physician behavior, have an important influence on physician practice styles during return patient visits. There are measurable differences in the established practice styles between family practice and internal medicine resident physicians, which may reflect differences in professional training programs.

Adult↗

PubMed1999

The impact of physician practice style on medical charges.

BACKGROUND: There are differences in styles of care among primary care physicians. The purpose of our study was to determine whether differences in physician practice styles and patient health status generate different medical charges. METHODS: New adult patients (N = 509) were randomized to primary care physicians, and use of medical care services and associated charges were monitored for 1 year. RESULTS: Controlling for baseline patient health status, a technically oriented style of care was associated with significantly higher specialty care, emergency department, diagnostic, and total charges. Some practice behaviors, however, were associated with lower charges; for example, a practice style emphasizing patient activation was associated with significantly lower primary care charges. Both a lower baseline patient health status and a health status that declined over the study period predicted higher charges. CONCLUSIONS: Measurable differences in practice style are associated with differing medical care charges. Patients' health status was also an important determinant of medical charges and had implications for the assessment of physician utilization patterns.

Adult↗

PubMed1998

Physician practice styles and patient outcomes: differences between family practice and general internal medicine.

OBJECTIVES: This study compared patient health status, patient satisfaction, and physician practice style between family practice and internal medicine. METHODS: New adult patients (n = 509) were prospectively and randomly assigned to family practice or internal medicine clinics at a university medical center and followed for 1 year of care. Practice styles were characterized by the Davis Observation Code. Self-reported health status (Medical Outcomes Study, Short Form-36) and patient satisfaction also were measured. RESULTS: There were no significantly different changes in self-reported health status or patient satisfaction between family practice and internal medicine physicians during the course of the study. Family practice initial encounters, however, were characterized by a style placing greater relative emphasis on health behavior and counseling, whereas internists used a more technical style. Improved health status scores after treatment were predicted by a practice style emphasis on counseling, whereas improvements in patient satisfaction scores were predicted by a style of care stressing patient activation. Although this is the first known randomized trial studying this issue, the conclusions are limited by a 38% loss of patients from enrollment to care and a loss of 18% at the 1-year follow-up evaluation. CONCLUSIONS: There were significant differences in practice styles between family physicians and internists; however, it was the physician's behavior, not specialty per se, that affected patient outcomes. A practice style emphasizing psychosocial aspects of care was predictive of improvements in patient health status, whereas a practice style emphasizing patient activation was predictive of improvements in patient satisfaction.

Adult↗

PubMed1997

Depression in primary care: patient factors that influence recognition.

BACKGROUND: Recognition of depression in primary care is both important and difficult. To study recognition of depression, we monitored care delivered to new adult patients randomly assigned to primary care providers. METHODS: At study entry, 508 patients completed the Beck Depression Inventory (BDI) and the Medical Outcomes Study Short-form Health Survey-36 (SF-36), a measure of health status. Chart notes were reviewed at the end of 1 year. RESULTS: Only 36 of 130 patients with elevated BDI scores > or = 9 (moderate-to-severe depression) were noted as depressed on the chart. Patient characteristics predicting chart notation of depression included BDI scores, health status, gender, and education. When controlling for these factors, neither age nor race were statistically significant in the prediction of the recognition of depression. Female patients were more likely to be diagnosed as depressed than men with comparable BDI and SF-36 scores. Greater patient education was associated with enhanced likelihood of diagnosis of depression. Both BDI scores and health status were important predictors of diagnosis of depression. All SF-36 subscales correlated highly with BDI scores, suggesting that these measures may lack adequate discriminant validity. CONCLUSIONS: Identifying diagnostic tendencies may help primary care providers improve detection of depression, a critical first step toward effective management.

Adult↗

PubMed1996

The influence of depression on physician-patient interaction in primary care.

BACKGROUND: Depression is common but not well diagnosed in primary care medicine. This study examines the influence of depression and its recognition on the physician-patient encounter. METHODS: A total of 508 new adult patients were assigned randomly to 105 primary care providers. Self-reported depression was determined by the Beck Depression Inventory (BDI) on entry to the study. Initial visits were videotaped and analyzed using the Davis Observation Code. Chart notes were reviewed for diagnosis of depression. RESULTS: Seventy-seven of the 508 study patients (15%) were identified as depressed in chart notes, while 130 patients (26%) had a BDI score > or = 9, indicating moderate to severe depression. Recognition of depression was associated with increased counseling, decreased time conducting physical examination, and an increase in overall visit length. Both elevated BDI scores and physician recognition of depression were associated with decreases in chatting. Failure to recognize depression was associated with increased time taking medical history. CONCLUSIONS: Results support the potential value of psychological screening instruments in primary care and provide information for training physicians in the recognition and management of depression. The content of office visits is different when patients are depressed or are diagnosed as depressed.

Adult↗

PubMed1995

The influence of gender on physician practice style.

As more women enter medicine, intriguing questions arise about how physician gender impacts practice style. To measure this influence in primary care encounters, 118 male and 132 female adult new patients, having no stated preference for a specific physician, were randomly assigned to university hospital primary care residents, and their initial encounters were videotaped. Forty-eight male and 33 female physicians participated. Patient health status was assessed before the visit with the Medical Outcomes Study Short-Form General Health Survey. Physician practice style was evaluated by using the Davis Observation Code to analyze videotapes of each initial visit. Patient satisfaction with medical care was assessed with satisfaction questionnaires. Contrary to prior reports, the difference between male and female physicians in total time spent with patients was small and statistically insignificant, and diminished further when controlling for patient gender and health status. Female physicians, however, were observed to engage in more preventive services and to communicate differently with their patients. These differences in practice style appear to explain partially the observed higher patient satisfaction scores for female physicians. This study underscores the importance of careful measurement and control of potential confounding factors in clarifying the impact of physician gender on practice style.

Adult↗

PubMed1993

The effect of patient health status on physician practice style.

BACKGROUND: The recent development of health status measures now facilitates the study of how patient health influences physician practice style. METHODS: The health status of 150 new patients at a university primary care center was assessed using the Medical Outcomes Study Short-Form General Health Survey. Videotapes of the physician-patient encounter were analyzed with the Davis Observation Code to explore the effect of patient health status on physician practice style. RESULTS: Regression analyses demonstrated that better health was predictive of a greater portion of the visit being spent on physical examination and chatting and a smaller portion of the visit on history taking. Counseling was predicted by diminished patient mental health scores. Preliminary evidence was found for different practice styles based on patient characteristics such as sex, age, education, and income. CONCLUSIONS: Results suggest that the physician-patient encounter is strongly influenced by health status. It will be crucial for future studies of physician-patient interaction to include an assessment of the patient's health status.

Adult↗

PubMed1993

The influence of physician practice behaviors on patient satisfaction.

BACKGROUND: Previous research on the relationship between physician behavior and patient satisfaction has not always used standardized terminology and instruments to measure physician behavior. The Davis Observation Code (DOC) provides a reliable and valid means of analyzing clinically relevant units of physician behavior. The units of behavior can then be related to patient satisfaction. METHODS: One hundred new patients randomly assigned to receive care from primary care residents at a university medical center outpatient facility were evaluated. Before seeing their physicians, patients completed a previsit questionnaire to determine their general level of satisfaction with health care. During the visit, the encounter was videotaped and physician behavior characterized using DOC. After the appointment, patients completed a visit-specific satisfaction questionnaire. Multiple regression analysis was used to model the visit-specific satisfaction variables in terms of DOC measurements. RESULTS: Total visit-specific satisfaction was positively related to previsit satisfaction (P < or = .05) and to time spent on health education (P < or = .001), physical examination (P < or = .05), and discussion of treatment effects (P < or = .01). There was a negative relationship with time spent on history taking (P < or = .01). Slightly more than 25% of the variability in satisfaction was explained by these five variables (R2 = .26). The general, humaneness, and quality/competence subscales of visit-specific satisfaction were also positively related to health education, physical examination, and treatment effects and negatively related to history taking. CONCLUSIONS: Patients are most satisfied with medical visits in which they talk about their specific therapeutic interventions, are examined, and receive health education. Extended general discussion of medical history is negatively related to satisfaction.

Adult↗

PubMed1993

A comparison of physician-patient interaction at fee-for-service and HMO sites.

Research has begun to identify elements in the practice environment that influence practice styles and health outcomes. One key element known to influence physician-patient interaction is the type of treatment environment: fee-for-service or health maintenance organization. Observers using the Davis Observation Code coded 82 physician-patient encounters in private practice settings and 72 encounters in a health maintenance organization. Populations were similar on all demographic measures except age, with health maintenance organization patients being older. Fee-for-service visits were shorter but included more coded behaviors per observation interval, resulting in equivalent total numbers of coded behaviors in each type of visit. Health maintenance organization visits included significantly more patient questions, preventive services, disease prevention, treatment planning, and discussion of substance use. Results may have reflected physician gender differences across sites or patient self-selection to sites rather than site differences. These results have implications for developing further research to explore treatment environment, process, and outcome.

Adult↗

PubMed1991

The relationship of physician medical interview style to patient satisfaction.

The results of previous studies on the relationship between patient satisfaction and specific interviewing behaviors have been difficult to generalize because most studies have examined small samples of patients at one clinical location, and have used initial or acute care visits where the patient and physician did not have an established relationship. The present collaborative study of medical interviewing provided an opportunity to collect interviews from 550 return visits to 127 different physicians at 11 sites across the country. Tape recordings were analyzed using the Roter Interaction Analysis System, and postvisit satisfaction questionnaires were administered to patients. A number of significant relationships were found between communication during the visit and the various dimensions of patient satisfaction. Physician question asking about biomedical topics (both open- and closed-ended questions) was negatively related to patient satisfaction; however, physician question asking about psychosocial topics was positively related. Physician counseling for psychosocial issues was also positively related to patient satisfaction. Similarly, patient talk about biomedical topics was negatively related to satisfaction, while patient talk regarding psychosocial topics was positively related. Furthermore, patients were less satisfied when physicians dominated the interview by talking more or when the emotional tone was characterized by physician dominance. The findings suggest that patients are most satisfied by interviews that encourage them to talk about psychosocial issues in an atmosphere that is characterized by the absence of physician domination.

Adult↗

PubMed1991

Development and validation of the Davis Observation Code.

Direct observation has demonstrated considerable power in the reliable and valid measurement of human behavior. A variety of direct methodologies have been applied to physician-patient interactions to answer different types of questions. This study describes the development and evaluation of a 20-item direct observation scale for physician-patient interactions, the Davis Observation Code (DOC). The study compared the rates of occurrence of four key physician behaviors measurable by both direct observation and chart audit: disease prevention, health education, health promotion, and compliance checking. Forty-nine videotaped physician-patient interactions were independently analyzed using the DOC. The medical record of each videotaped encounter was also reviewed. Reliability determined by inter-rater agreement regarding the presence/absence of each was acceptable for both direct observation and chart audit. Rates of occurrence of each target behavior differed between the two methods of review; chart audit consistently yielded lower rates. Nonparametric correlation analyses yielded phi values ranging from .12 to .49, suggesting low concurrent validity. Most of the discordance between the results of the videotaped observation and chart audit involved underreporting in the chart of observed behavior by the physician. Implications of the findings for health care delivery research are discussed.

Communication↗

PubMed1989

Utilization of hospital services. A comparison of internal medicine and family practice.

Five hundred twenty new patients were randomly and prospectively assigned to receive care in the Internal Medicine Clinic or Family Practice Clinic of a large university hospital. Previous analyses of outpatient data demonstrated that the frequency of visits to the clinic of primary care, acute care clinic, emergency room, and consultant clinics were all significantly higher for patients randomized to internal medicine compared with family practice. In the present study, patients' charts were reviewed for information regarding hospitalizations. During the 3.4-year study period, there were a total of 61 hospital admissions for internal medicine (35 of 249 patients), and 58 for family practice (27 to 271 patients). Age (mean 47 years) and sex of patients in both groups were equivalent. The average total cost of hospitalization for each patient was greater for those randomized to the Internal Medicine Clinic: $7,193 for internal medicine patients as compared with $5,764 for family practice patients. The professional costs per hospitalization showed greater variation: $913 for Internal Medicine Clinic patients and $629 for Family Practice Clinic patients. Internal Medicine Clinic patients had a longer mean length of hospitalization (7.5 days) when compared with that of Family Practice Clinic patients (6.3 days). It can be concluded that in this clinical environment the hospitalization patterns are different for patients assigned to the Internal Medicine Clinic compared with the Family Practice Clinic: both cost and length of care for hospitalization are less for those followed by the Family Practice Clinic.

Adult↗