Biomedical subjects

M A Goodwin

Publications and source records attributed to M A Goodwin.

At least 19 recordsLinked to original sources

PubMed2001

Does health habit counseling affect patient satisfaction?

BACKGROUND: Health behavior advice can potentially prevent a large burden of illness, but the acceptability of this advice to patients is not well understood. This study assessed whether physician discussion of behavioral risk factors decreases patient satisfaction with the outpatient visit. METHODS: In a cross-sectional study of 2,459 consecutive adult outpatient visits to 138 community family physicians in Northeast Ohio, the association of health habit counseling, measured by direct observation, with patient satisfaction, assessed by a modified subscale of the MOS 9-item visit rating scale, was calculated by logistic regression. RESULTS: In analyses controlling for patient mix, discussion of diet, exercise, alcohol and other substance use, sexually transmitted disease, and HIV prevention was not associated with patient satisfaction. Patients who were asked about their tobacco use or counseled about quitting were more likely to be very satisfied with the physician. CONCLUSIONS: Discussion of health behavior change, as practiced by community family physicians, is not associated with diminished patient satisfaction. In fact, tobacco use assessment and cessation counseling are associated with greater satisfaction.

Counseling↗

PubMed2001

A clinical trial of tailored office systems for preventive service delivery. The Study to Enhance Prevention by Understanding Practice (STEP-UP).

BACKGROUND: The potential of primary care practice settings to prevent disease and morbidity through health habit counseling, screening for asymptomatic disease, and immunizations has been incompletely met. This study was designed to test a practice-tailored approach to increasing preventive service delivery with particular emphasis on health habit counseling. DESIGN: Group randomized clinical trial and multimethod process assessment. SETTING/PARTICIPANTS: Seventy-seven community family practices in northeast Ohio. INTERVENTION: After a 1-day practice assessment, a nurse facilitator met with practice clinicians and staff and assisted them with choosing and implementing individualized tools and approaches aimed at increasing preventive service delivery. MAIN OUTCOME MEASURE: Summary scores of the health habit counseling, screening and immunization services recommended by the U.S. Preventive Services Task Force up to date for consecutive patients during randomly selected chart review days. RESULTS: A significant increase (p=0.015) in global preventive service delivery rates at the 1-year follow-up was found in the intervention group (31% to 42%) compared to the control group (35% to 37%). Rates specifically for health habit counseling (p=0.007) and screening services (p=0.048) were increased, but not for immunizations. CONCLUSIONS: An approach to increasing preventive service delivery that is individualized to meet particular practice needs can increase global preventive service delivery rates.

Adult↗

PubMed2001

The delivery of preventive services for patient symptoms.

BACKGROUND: Although data are available on rates of delivery of preventive services by primary care physicians, the proportion of services delivered because of related symptoms or signs, rather than for primary or secondary prevention of disease is not known. METHODS: Research nurses directly observed 4454 consecutive visits to 138 practicing family physicians. Direct observation was used to identify delivery of 36 different services recommended by the U.S. Preventive Services Task Force and to assess whether delivery of these services was associated with related signs or symptoms. RESULTS: One or more preventive services were delivered in 33% of visits, with rates ranging from 0.2% (HIV prevention) to 19.9% (tobacco counseling). In contrast to pure prevention, services were frequently performed for assessment or care of symptoms or signs, with the ratio ranging from 0% (eye examination; car seat, poison control, and HIV prevention counseling) to 66.7% (hearing test). Physicians varied considerably in the frequency at which their delivery of recommended preventive services was associated with patient symptoms, from 0% to 100% for screening services and from 0% to 100% for counseling services. CONCLUSIONS: Because of the illness focus of most primary care visits, preventive service delivery is often associated with related signs or symptoms. Care of illnesses appears to present an important impetus and perhaps teachable moments for providing preventive care. Clinician variability in preventive service delivery for patient symptoms shows an opportunity to improve the primary and secondary prevention focus of practice to meet public health prevention goals.

Adolescent↗

PubMed2001

Is diabetes treated as an acute or chronic illness in community family practice?

OBJECTIVE: Poor quality of diabetes care has been ascribed to the acute care focus of primary care practice. A better understanding of how time is spent during outpatient visits for diabetes compared with visits for acute conditions and other chronic diseases may facilitate the design of programs to enhance diabetes care. RESEARCH DESIGN AND METHODS: Research nurses directly observed consecutive outpatient visits during two separate days in 138 community family physician offices. Time use was categorized into 20 different behaviors using the Davis Observation Code (DOC). Time use was compared for visits for diabetes, other chronic conditions, and acute illnesses during 1,867 visits by patients > or =40 years of age. RESULTS: Of 20 DOC behavioral categories, 10 exhibited differences among the three groups. Discriminant analysis identified two distinct factors that distinguished visits for chronic disease from visits for acute illness and visits for diabetes from those for other chronic diseases. Compared with visits for other chronic diseases, visits for diabetes devoted a greater proportion of time to nutrition counseling, health education, and feedback on results and less time to chatting. Compared with visits for acute illness, visits for diabetes were longer and involved a higher proportion of dietary advice, negotiation, and assessment of compliance. CONCLUSIONS: Visits for diabetes are distinct from visits for other chronic diseases and acute illnesses in ways that may facilitate patient self-management. Novel quality-improvement interventions could support and expand existing differences between family physicians' current approaches to care of diabetes and other chronic and acute illnesses.

Acute Disease↗

PubMed2001

Time use in clinical encounters: are African-American patients treated differently?

Racial disparities in the process and outcome of health care may be partially explained by differences in time use during outpatient visits by African-American and white patients. This study was undertaken to determine whether physicians use their time in clinical encounters with African-American patients differently than with white patients. This study was a multimethod, cross-sectional study conducted between October 1994 and August 1995 in 84 family practices in northeast Ohio. Participants were 4,352 white and African-American outpatients visiting 138 physicians. Time use during the patient visit was measured by the Davis Observation Code, which categorizes every 20-second interval into 20 different behavioral categories. Among 3,743 white and 509 African-American patients, after adjustment for potential confounders, visits by African-American patients were slightly longer than visits with white patients (10.7 vs. 10.1 minutes, p = 0.027). After further adjustment for multiple comparisons, physicians spent a lower proportion of time intervals with African-American patients as compared to white patients planning treatment (29.0% vs. 32.1%, p < 0.001), providing health education (16.4% vs. 19.7%, p < 0.001), chatting (5.2% vs. 7.6%, p < 0.001), assessing patients' health knowledge (0.8% vs. 1.2%, p < 0.001), and answering questions (5.8% vs. 6.9%, p = 0.002). Physicians spent relatively more time intervals with African-American patients discussing what is to be accomplished (9.3% vs. 7.6%, p < 0.001) and providing substance use assessment and advice (0.8% vs. 0.4%, p = 0.001). In conclusion, physicians spend time differently with African-American as compared with white patients. These differences may represent appropriate tailoring of services to meet unique needs, but could also represent racial bias.

Black or African American↗

PubMed2000

Evaluation and management services. A comparison of medical record documentation with actual billing in community family practice.

OBJECTIVE: To compare the concordance of family physicians' billing for evaluation and management services with medical record documentation. DESIGN: Multi-method, cross-sectional observation study. SETTING: Eighty-four family practices in northeast Ohio. PARTICIPANTS: Four thousand fifty-four outpatients visiting 138 family physicians. MAIN OUTCOME MEASURE: The degree of concordance between evaluation and management Current Procedural Terminology codes billed by physicians, with those codes assigned by trained research nurses using American Medical Association criteria to code medical records for the same visits. RESULTS: Discrepancies between the multifactorial nature of family practice outpatient visits and the Current Procedural Terminology coding criteria, which dictate overcoding for depth rather than breadth, made coding difficult (multiple-rater kappa statistic between research nurses = 0.36). Among 4137 outpatient visits with complete billing information, 57% of the Current Procedural Terminology codes generated by medical record review were concordant with the actual billing code assigned by physicians. Undercoding and overcoding occurred at a similar frequency (21% and 19%, respectively) and differed by more than 1 code in fewer than 4% of visits. Visits by new patients were more likely to be inaccurately coded than visits by established patients. CONCLUSIONS: Record documentation by community family physicians largely reflects the level of services billed using evaluation and management codes. Undercoding is as common as overcoding. Efforts from regulatory agencies should be redirected from penalizing physicians for overcoding to focusing on the development of coding criteria that reflect the multifactorial nature of outpatient primary care practice.

Cross-Sectional Studies↗

PubMed2000

Direct observation of rates of preventive service delivery in community family practice.

BACKGROUND: Data on preventive service delivery in primary care practice have been limited by indirect methods of measurement. This study describes directly observed rates of preventive service delivery during outpatient visits to community family physicians. METHODS: In a multimethod cross-sectional study, research nurses directly observed consecutive patient visits in the offices of 138 family physicians in Northeast Ohio. Patient eligibility for services recommended by the U.S. Preventive Services Task Force was determined from medical record review. Service delivery was assessed by direct observation of outpatient visits. Rates of delivery of specific preventive services were computed. Global summary measures were calculated for health habit counseling, screening, and immunization services. RESULTS: Among 4,049 visits by established patients with available medical records, wide variation was observed among rates of different preventive services delivered during well-care visits. During illness visits, rates were uniformly low for all preventive services. Counseling services were delivered at only slightly lower rates during illness visits compared to well visits. Patients were up to date on 55% of screening, 24% of immunization, and 9% of health habit counseling services. CONCLUSION: Rates of preventive service delivery are low. Illness visits are important opportunities to deliver preventive services, particularly health habit counseling, to patients. Preventive service delivery summary scores are useful in providing a patient population perspective on the delivery of preventive services and in focusing attention on delivery of a comprehensive portfolio of services.

Adult↗

PubMed2000

Facilitating participatory decision-making: what happens in real-world community practice?

BACKGROUND: Participatory decision-making (PDM), a widely held ideal, depends on physician facilitation of patient participation. However, little is known about how PDM facilitation is actualized in outpatient primary care. OBJECTIVES: The objective of this study was to describe the prevalence of physician facilitation of PDM in community family practices and associated physician, patient, and visit characteristics. RESEARCH DESIGN: This was a cross-sectional observational study. SUBJECTS: The study included 3,453 patients seen by 138 family physicians in 84 community practices. MAIN OUTCOME MEASURES: Research nurses directly observed PDM facilitation in consecutive adult outpatient visits. The association between PDM facilitation and patient, physician, and visit characteristics was assessed with multilevel multivariable regression. RESULTS: PDM facilitation occurred during 25% of observed patient visits. Rates varied considerably among physicians, from 0% to 79% of visits. Patient satisfaction was not associated with PDM facilitation. In multivariable analyses, employed physicians, chronic illness visits, longer visit duration, and visits involving referral were independently associated with PDM facilitation. Visits in which greater time was spent planning treatment and conducting health education were also more likely to involve facilitation of PDM. CONCLUSIONS: Community family physicians facilitate PDM at highly variable rates but focus it on patients with the greatest medical needs and most complex levels of decision making. This selective approach appears to meet patient expectations, because PDM facilitation and patient satisfaction are not associated. If patient participation is to be more widely incorporated into outpatient primary care, it must be addressed within the complexity and multiple demands of community practice.

Adolescent↗

PubMed2000

Two physician styles of focusing on the family.

BACKGROUND: Previous research has identified 2 styles of family physicians' focus on the patient's family: (1) using the family history as the context of care of the patient; and (2) maintaining a family orientation with the family as the unit of care. The purpose of our study was to determine whether these styles affect patient outcomes and time use during outpatient visits. METHODS: In a cross-sectional study, data on 4454 outpatient visits to 138 community family physicians were collected using direct observation, patient and physician questionnaires, and medical record review. We computed partial correlations between the physician's family practice style score and patient outcomes for delivery of preventive services, patient visit satisfaction, and patient-reported delivery of specific components of primary care. We controlled for relevant patient characteristics. RESULTS: The patients of the physicians using either practice style had similar levels of satisfaction with coordination of care and interpersonal communication, and their value of continuity of care was comparable. Patients of physicians with a family-history style, however, rated their physicians lower on a measure of in-depth knowledge of the patient and family but higher on preventive services delivery. Differences in time use during the visit reflected how these styles were manifested during the outpatient visit. CONCLUSIONS: The different styles physicians use to focus on the family affect the process and outcomes of patient care. This difference may be explained by the developmental life cycle of family physicians, as younger physicians may be more focused on family history and older physicians may have a more family-oriented focus. Physicians may need to find alternate ways of meeting those patient needs not well met by their predominant practice style.

Cross-Sectional Studies↗

PubMed1999

Direct observation of health-habit counseling of adolescents.

OBJECTIVES: To determine the rate of health-habit counseling of adolescents seeing community family physicians and to identify the factors associated with the delivery of recommended preventive counseling services. DESIGN: Cross-sectional multimethod study emphasizing direct observation of patient visits. SETTING: Community family practices in northeast Ohio. PATIENTS OR OTHER PARTICIPANTS: Adolescents (n = 445) aged 11 to 21 years who were being seen for outpatient visits to community family physicians (n = 119) during 2 days of observation by trained research nurses. MAIN OUTCOME MEASURE: Direct observation of the delivery of clinical preventive counseling services recommended by the Guidelines for Adolescent Preventive Services. RESULTS: During the 445 visits made by adolescents, the most frequently delivered counseling service was exercise advice (13%). At least 1 health-habit counseling service was delivered during 38% of visits. In multivariable analyses, older patient age was strongly associated with increased service delivery. Visits for well care, longer visits, and new patient visits were also associated with the provision of counseling. Visits including preventive counseling services were on average 2.5 minutes longer than visits without preventive counseling. CONCLUSIONS: The rates of delivery of preventive counseling services in clinical practice were low, raising concern about the feasibility of current recommendations. The practical implementation of prevention guidelines may require a greater use of well-care visits and longer patient visits than are currently used in community family practice.

Adolescent↗

PubMed1999

Direct observation of exercise counseling in community family practice.

BACKGROUND: Although physical activity is important for the prevention and management of a variety of common chronic diseases, the prevalence and patient and visit characteristics associated with provision of physical activity advice by community family physicians is not well understood. METHODS: In a cross-sectional multi-method study of 138 family physicians in northeast Ohio, exercise advice was measured by direct observation and patient report of consecutive patient visits to 138 practicing family physicians. The association of exercise advice with patient and visit characteristics, assessed by direct observation, medical record review, patient exit questionnaire, and billing data, was determined by logistic regression analysis. RESULTS: In 4,215 visits by patients older than 2 years of age, exercise counseling was observed during 927 visits (22.3%), but reported by only 13% of patients returning questionnaires. The mean time spent counseling about exercise was 0.78 minutes, with a range of 0.33 to 6.00 minutes (SD = 0.67). Exercise advice was more common during longer visits, visits for well care, and visits by patients who were older, male, and had chronic illnesses for which lack of physical activity is a risk factor. CONCLUSIONS: Exercise counseling is relatively common during outpatient visits to family physicians, and is more commonly given to patients with risk factors. Multiple patient visits over time present opportunities to integrate exercise counseling among the competing demands of primary care practice.

Adult↗

PubMed1998

Generation of a mutant infectious bursal disease virus that does not cause bursal lesions.

A reverse genetics system for birnavirus, based on synthetic transcripts of the infectious bursal disease virus (IBDV) genome, was recently developed (E. Mundt and V. N. Vakharia, Proc. Natl. Acad. Sci. USA 93:11131-11136, 1996). To study the function of the 17-kDa nonstructural (NS) protein in viral growth and pathogenesis, we constructed a cDNA clone of IBDV segment A in which the first and only initiation codon (ATG) of NS protein was mutated to a stop codon (TAG). Transfection of Vero cells with combined transcripts of either modified or unmodified segment A, and with segment B, generated viable IBDV progeny. When chicken embryo fibroblast cells infected with transfectant viruses were analyzed by immunofluorescence assays using NS-specific antiserum, the mutant virus did not yield a fluorescence signal, indicating a lack of NS protein expression. Furthermore, replication kinetics and cytotoxic effects of the mutant virus were compared with those of the parental attenuated vaccine strain of IBDV (D78) in vitro. The mutant virus grew to slightly lower titers than D78 virus and exhibited decreased cytotoxic and apoptotic effects in cell culture. To evaluate the characteristics of the recovered viruses in vivo, we inoculated 3-week-old chickens with D78 or mutant virus and analyzed their bursa for histopathological lesions. The recovered D78 virus caused microscopic lesions and atrophy of the bursa, while the mutant virus failed to induce any pathological lesions or clinical signs of disease. In both instances, the virus was recovered from the bursa, and the presence or absence of mutation in these viruses was confirmed by nucleotide sequence analysis of NS gene. Although the mutant virus exhibited a delay in replication in vivo, it induced levels of IBDV neutralizing antibodies that were similar to those of D78 virus. In addition, no reversion of mutation was detected in the mutant virus recovered from inoculated chickens. These results demonstrate that NS protein is dispensable for viral replication in vitro and in vivo and that it plays an important role in viral pathogenesis. Thus, generation of such NS protein-deficient virus will facilitate the study of immunosuppression and aid in the development of live-attenuated vaccines for IBDV.

Animals↗

PubMed1998

Illuminating the 'black box'. A description of 4454 patient visits to 138 family physicians.

BACKGROUND: The content and context of family practice outpatient visits have never been fully described, leaving many aspects of family practice in a "black box," unseen by policymakers and understood only in isolation. This article describes community family practices, physicians, patients, and outpatient visits. METHODS: Practicing family physicians in northeast Ohio were invited to participate in a multimethod study of the content of primary care practice. Research nurses directly observed consecutive patient visits, and collected additional data using medical record reviews, patient and physician questionnaires, billing data, practice environment checklists, and ethnographic fieldnotes. RESULTS: Visits by 4454 patients seeing 138 physicians in 84 practices were observed. Outpatient visits to family physicians encompassed a wide variety of patients, problems, and levels of complexity. The average patient paid 4.3 visits to the practice within the past year. The mean visit duration was 10 minutes. Fifty-eight percent of visits were for acute illness, 24% for chronic illness, and 12% for well care. The most common uses of time were history-taking, planning treatment, physical examination, health education, feedback, family information, chatting, structuring the interaction, and patient questions. CONCLUSIONS: Family practice and patient visits are complex, with competing demands and opportunities to address a wide range of problems of individuals and families over time and at various stages of health and illness. Multimethod research in practice settings can identify ways to enhance the competing opportunities of family practice to improve the health of their patients.

Adult↗

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↗