Biomedical subjects

Peter Franks

Publications and source records attributed to Peter Franks.

At least 19 recordsLinked to original sources

PubMed2006

Does the content of primary care visits differ by the racial composition of physicians' practices?

PURPOSE: The study compared the content of primary care visits between physicians with larger and smaller African American practices. METHODS: We compared the content of primary care adult visits between physicians with larger and smaller African American practices using data from the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey 1997 to 2002. Larger African American practice (>14% of primary care visits by African Americans) was empirically defined to conform with previous studies. RESULTS: Larger African American practices comprised 24% of all practices but accounted for 80% of all visits by African American patients. In adjusted analyses, physicians with larger African American practices were less likely to refer patients to specialists (adjusted odds ratio 0.77; 95% confidence internal 0.61-0.98) and marginally less likely to perform rectal examinations (adjusted odds ratio 0.84; 95% confidence interval 0.56-1.00) but were more likely to schedule a return appointment (adjusted odds ratio 1.25; 95% confidence interval, 1.02-1.52). However, there were no other significant differences in the reported content of the office visits. Results were not altered when different cutoffs for larger African American practices were used or when obstetricians-gynecologists were excluded from the analyses. CONCLUSION: There are few differences in the content of office visits between physicians with larger and smaller African American practices.

Adult↗

PubMed2005

The burden of disease associated with being African-American in the United States and the contribution of socio-economic status.

The burden of disease associated with being African-American in the US, and the contribution of socio-economic status (SES) to that burden have not been quantified. We derived burden of disease estimates for African-Americans and whites by age group, with and without adjustment for SES (income and education). We used (1) EQ-5D Index scores from the 2000 US Medical Expenditure Panel Survey to derive quality-adjusted life year (QALY) compatible estimates of health-related quality of life (HRQL); (2) 1990-1992 US National Health Interview Survey data linked to National Death Index data through 1995 to derive mortality risks; and (3) 2000 US mortality data from the National Center for Health Statistics to derive current mortality estimates for the US population. We found that relative to whites, African-Americans suffer 67,000 more deaths annually, resulting in 2.2 million years of life lost, and 1.1 million years after SES adjustment. Total QALYs lost (HRQL and mortality) dropped from 2.3 million to 902,000 after SES adjustment. SES differences between African-Americans and whites appear to explain all the HRQL disparity but only half the mortality disparity. Better understanding of the disparate effects of SES may inform interventions to address health disparities adversely affecting African-Americans.

Adult↗

PubMed2005

Studying physician effects on patient outcomes: physician interactional style and performance on quality of care indicators.

Many prior studies which suggest a relationship between physician interactional style and patient outcomes may have been confounded by relying solely on patient reports, examining very few patients per physician, or not demonstrating evidence of a physician effect on the outcomes. We examined whether physician interactional style, measured both by patient report and objective encounter ratings, is related to performance on quality of care indicators. We also tested for the presence of physician effects on the performance indicators. Using data on 100 US primary care physician (PCP) claims data on 1,21,606 of their managed care patients, survey data on 4746 of their visiting patients, and audiotaped encounters of 2 standardized patients with each physician, we examined the relationships between claims-based quality of care indicators and both survey-derived patient perceptions of their physicians and objective ratings of interactional style in the audiotaped standardized patient encounters. Multi-level models examined whether physician effects (variance components) on care indicators were mediated by patient perceptions or objective ratings of interactional style. We found significant physician effects associated with glycohemoglobin and cholesterol testing. There was also a clinically significant association between better patient perceptions of their physicians and more glycohemoglobin testing. Multi-level analyses revealed, however, that the physician effect on glycohemoglobin testing was not mediated by patient perceived physician interaction style. In conclusion, similar to prior studies, we found evidence of an apparent relationship between patient perceptions of their physician and patient outcomes. However, the apparent relationships found in this study between patient perceptions of their physicians and patient care processes do not reflect physician style, but presumably reflect unmeasured patient confounding. Multi-level modeling may contribute to better understanding of the relationships between physician style and patient outcomes.

Adult↗

PubMed2005

Influence of patients' requests for direct-to-consumer advertised antidepressants: a randomized controlled trial.

CONTEXT: Direct-to-consumer (DTC) advertising of prescription drugs in the United States is both ubiquitous and controversial. Critics charge that it leads to overprescribing, while proponents counter that it helps avert underuse of effective treatments, especially for conditions that are poorly recognized or stigmatized. OBJECTIVE: To ascertain the effects of patients' DTC-related requests on physicians' initial treatment decisions in patients with depressive symptoms. DESIGN: Randomized trial using standardized patients (SPs). Six SP roles were created by crossing 2 conditions (major depression or adjustment disorder with depressed mood) with 3 request types (brand-specific, general, or none). SETTING: Offices of primary care physicians in Sacramento, Calif; San Francisco, Calif; and Rochester, NY, between May 2003 and May 2004. PARTICIPANTS: One hundred fifty-two family physicians and general internists recruited from solo and group practices and health maintenance organizations; cooperation rates ranged from 53% to 61%. INTERVENTIONS: The SPs were randomly assigned to make 298 unannounced visits, with assignments constrained so physicians saw 1 SP with major depression and 1 with adjustment disorder. The SPs made a brand-specific drug request, a general drug request, or no request (control condition) in approximately one third of visits. MAIN OUTCOME MEASURES: Data on prescribing, mental health referral, and primary care follow-up obtained from SP written reports, visit audiorecordings, chart review, and analysis of written prescriptions and drug samples. The effects of request type on prescribing were evaluated using contingency tables and confirmed in generalized linear mixed models that accounted for clustering and adjusted for site, physician, and visit characteristics. RESULTS: Standardized patient role fidelity was excellent, and the suspicion rate that physicians had seen an SP was 13%. In major depression, rates of antidepressant prescribing were 53%, 76%, and 31% for SPs making brand-specific, general, and no requests, respectively (P<.001). In adjustment disorder, antidepressant prescribing rates were 55%, 39%, and 10%, respectively (P<.001). The results were confirmed in multivariate models. Minimally acceptable initial care (any combination of an antidepressant, mental health referral, or follow-up within 2 weeks) was offered to 98% of SPs in the major depression role making a general request, 90% of those making a brand-specific request, and 56% of those making no request (P<.001). CONCLUSIONS: Patients' requests have a profound effect on physician prescribing in major depression and adjustment disorder. Direct-to-consumer advertising may have competing effects on quality, potentially both averting underuse and promoting overuse.

Adjustment Disorders↗

PubMed2005

Measuring patient-centered communication in patient-physician consultations: theoretical and practical issues.

The goal of patient-centered communication (PCC) is to help practitioners provide care that is concordant with the patient's values, needs and preferences, and that allows patients to provide input and participate actively in decisions regarding their health and health care. PCC is widely endorsed as a central component of high-quality health care, but it is unclear what it is and how to measure it. PCC includes four communication domains: the patient's perspective, the psychosocial context, shared understanding, and sharing power and responsibility. Problems in measuring PCC include lack of theoretical and conceptual clarity, unexamined assumptions, lack of adequate control for patient characteristics and social contexts, modest correlations between survey and observational measures, and overlap of PCC with other constructs. We outline problems in operationalizing PCC, choosing tools for assessing PCC, choosing data sources, identifying mediators of PCC, and clarifying outcomes of PCC. We propose nine areas for improvement: (1) developing theory-based operational definitions of PCC; (2) clarifying what is being measured; (3) accounting for the communication behaviors of each individual in the encounter as well as interactions among them; (4) accounting for context; (5) validating of instruments; (6) interpreting patient ratings of their physicians; (7) doing longitudinal studies; (8) examining pathways and mediators of links between PCC and outcomes; and (9) dealing with the complexity of the construct of PCC. We discuss the use of observational and survey measures, multi-method and mixed-method research, and standardized patients. The increasing influence of the PCC literature to guide medical education, licensure of clinicians, and assessments of quality provides a strong rationale for further clarification of these measurement issues.

Communication↗

PubMed2005

Is expanding Medicare coverage cost-effective?

BACKGROUND: Proposals to expand Medicare coverage tend to be expensive, but the value of services purchased is not known. This study evaluates the efficiency of the average private supplemental insurance plan for Medicare recipients. METHODS: Data from the National Health Interview Survey, the National Death Index, and the Medical Expenditure Panel Survey were analyzed to estimate the costs, changes in life expectancy, and health-related quality of life gains associated with providing private supplemental insurance coverage for Medicare beneficiaries. Model inputs included socio-demographic, health, and health behavior characteristics. Parameter estimates from regression models were used to predict quality-adjusted life years (QALYs) and costs associated with private supplemental insurance relative to Medicare only. Markov decision analysis modeling was then employed to calculate incremental cost-effectiveness ratios. RESULTS: Medicare supplemental insurance is associated with increased health care utilization, but the additional costs associated with this utilization are offset by gains in quality-adjusted life expectancy. The incremental cost-effectiveness of private supplemental insurance is approximately $24,000 per QALY gained relative to Medicare alone. CONCLUSION: Supplemental insurance for Medicare beneficiaries is a good value, with an incremental cost-effectiveness ratio comparable to medical interventions commonly deemed worthwhile.

Aged↗

PubMed2005

Relationship among sociodemographic factors, clinical conditions, and health-related quality of life: examining the EQ-5D in the U.S. general population.

INTRODUCTION: Health-related quality of life (HRQL) measures are used increasingly in evaluations of clinical and population-based outcomes and in economic analyses. We investigate the influence of demographic, socioeconomic, and chronic disease factors on the HRQL of a representative U.S. sample. METHODS: We examined data from 13,646 adults in the 2000 Medical Expenditure Panel Survey, a nationally representative sample of the U.S. general population, who completed a self-administered questionnaire containing the EQ-5D, a preference-based measure. We assessed the relationships between EQ-5D scores and sociodemographic variables, including age, sex, race/ethnicity, income and education, and six common chronic conditions. RESULTS: In fully adjusted models, EQ-5D scores decreased with increasing category of age and were lower for persons with a lower income and educational attainment as well as each of the six conditions. Although the EQ-5D scores were lower for females and Whites compared with Blacks such differences were not of a magnitude considered to be clinically important. CONCLUSIONS: In the U.S., sociodemographic factors and clinical conditions are strongly associated with scores on the EQ-5D. Population health studies and risk-adjustment models should account and adjust for these factors when assessing the performance of health programs and clinical care.

Adolescent↗

PubMed2005

The cost effectiveness of health insurance.

BACKGROUND: Although studies have examined both the adverse consequences of lacking health insurance and the costs of insuring the uninsured, there are no estimates of the value of providing health insurance to those currently uninsured. OBJECTIVE: To examine the value associated with providing insurance to those currently uninsured through an incremental cost-effectiveness analysis. METHODS: People aged 25 to 64 in both the National Health Interview Survey (with 2-year mortality follow-up) and the Medical Expenditure Panel Survey were examined to estimate the contribution of sociodemographic, health, and health behavior characteristics on insured persons' quality-adjusted life years (QALYs) and healthcare costs. Parameter estimates from these regression models were used to predict QALYs and costs associated with insuring the uninsured, given their characteristics for 1996. Markov decision-analysis modeling was then employed to calculate incremental cost-effectiveness ratios. RESULTS: The incremental cost-effectiveness of insurance for the average 25-year-old adult (through age 64) is approximately $35,000 per QALY gained (range $21,000 to $48,000). The incremental cost-effectiveness ratio becomes more favorable as people approach age 65. CONCLUSIONS: The additional health care purchased with health insurance provides gains in quality-adjusted life at costs that compare favorably to those of other programs and medical interventions society now chooses to fund.

Adult↗

PubMed2005

Venous thromboembolism after spinal cord injury: incidence, time course, and associated risk factors in 16,240 adults and children.

OBJECTIVE: To analyze the incidence of venous thromboembolism (VTE) after spinal cord injury (SCI). DESIGN: Retrospective cohort analysis of all SCI cases (16,240) in California from 1991 through 2001. SETTING: All public hospitals in California. PARTICIPANTS: Subjects (cases) coded as having complete or incomplete SCI. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Diagnosis of VTE or death within 91 days of the day of hospital admission. RESULTS: For all cases, the 91-day cumulative incidence of VTE was 5.4%. In a multivariate model, significant predictors of VTE included male sex (odds ratio [OR]=1.4; 95% confidence interval [CI], 1.2-1.7), African-American race (OR=1.6; 95% CI, 1.3-1.9), complete paraplegia versus tetraplegia (OR=1.8; 95% CI, 1.4-2.3), and presence of 3 or more comorbid conditions versus none (OR=1.6; 95% CI, 1.3-2.1). Age less than 14 years was predictive of not developing VTE (OR=0.2; 95% CI, 0.1-0.7). The incidence of VTE did not change significantly over the 11-year time period (P=.07), and VTE was not a significant predictor of death in the first 91 days after hospitalization. CONCLUSIONS: The incidence of VTE in SCI patients in California did not change between 1991 and 2001. We identified specific risk factors for VTE. Further studies are needed to determine if prompt initiation of medical prophylaxis in high risk subjects reduces the incidence of symptomatic VTE.

Adolescent↗

PubMed2005

Emotion language in primary care encounters: reliability and validity of an emotion word count coding system.

OBJECTIVES: To develop a reliable and valid computer coded measure to assess emotional expression from transcripts of physician-patient interactions. METHODS: Physician encounters with two standardized patients (SPs) were audiotaped. Fifty patients from each physician (n = 100 primary care physicians) completed surveys that assessed patients' perceptions of their relationships with physicians. Audio-recordings of 193 patient-physician encounters were transcribed and computer-coded to derive a percent emotion words, and research assistants completed the Measure of Patient-Centered Communication (MPCC). RESULTS: After adjustment for potential confounders, regression analyses revealed physicians' use of emotion words and the MPCC contribute independently to patients' and SPs' perceptions of their relationship with physicians. CONCLUSIONS: The computerized coding of emotion words shows promise as a reliable, valid, and simple method to code transcript data of physician-patient interactions. This method may be expanded to examine other aspects of physician language and does not require coder training.

Attitude of Health Personnel↗

PubMed2005

The income-associated burden of disease in the United States.

In this study, we estimate the total burden of disease associated with income in the US. We calculate the relationships between income and life expectancy, health-adjusted life expectancy, annual years of life lost (YLLs), and health adjusted life years (HALYs). We used the 2000 US Medical Expenditure Panel Survey to derive quality of life estimates by income and age, the 1990-1992 US National Health Interview Survey linked to National Death Index data through the end of 1995 to derive mortality risks by income and by age, and 2000 US mortality data from the National Center for Health Statistics to derive current mortality estimates for the US population by age-group. The bottom 80% of adult income earners' life expectancy is 4.3 years and 5.8 HALYs shorter relative to those in the top 20% of earnings. This translates into the loss of 11 million YLLs and 17.4 million HALYs each year. Compared with persons living above the poverty threshold, those living below the poverty threshold live an average of 3.2 million fewer HALYs per year-a difference of 8.5 HALYs per individual between age 18 and death. The income-associated burden of disease appears to be a leading cause of morbidity and mortality in the US.

Adolescent↗

PubMed2005

Factors affecting resident performance: development of a theoretical model and a focused literature review.

PURPOSE: The clinical performances of physicians have come under scrutiny as greater public attention is paid to the quality of health care. However, determinants of physician performance have not been well elucidated. The authors sought to develop a theoretical model of physician performance, and explored the literature about factors affecting resident performance. METHOD: Using expert consensus panel, in 2002-03 the authors developed a hypothesis-generating model of resident performance. The developed model had three input factors (individual resident factors, health care infrastructure, and medical education infrastructure), intermediate process measures (knowledge, skills, attitudes, habits), and final health outcomes (affecting patient, community and population). The authors used factors from the model to focus a PubMed search (1967-2002) for all original articles related to the factors of individual resident performance. RESULTS: The authors found 52 original studies that examined factors of an individual resident's performance. They describe each study's measurement instrument, study design, major findings, and limitations. Studies were categorized into five domains: learning styles/personality, social/financial factors, practice preferences, personal health, and response to job environment. Few studies examined intermediate or final performance outcomes. Most were single-institution, cross-sectional, and survey-based studies. CONCLUSIONS: Attempting to understand resident performance without understanding factors that influence performance is analogous to examining patient adherence to medication regimens without understanding the individual patient and his or her environment. Based on a systematic review of the literature, the authors found few discrete associations between the factors of individual resident and the resident's actual job performance. Additionally, they identify and discuss major gaps in the educational literature.

Adult↗

PubMed2005

Racial disparity in surgical complications in New York State.

OBJECTIVE: To examine the relationship between race and surgical complications. SUMMARY BACKGROUND DATA: Blacks have been reported to experience higher rates of surgical complications than whites, but the reasons are not known. METHODS: The effect of the black race on risk of any surgical complication (from the Agency for Healthcare Research and Quality's patient safety indicators) was examined using New York State (NYS) hospital discharge data from 1998 to 2000. Sequential, hierarchical analyses controlled for: 1) patient age and gender, 2) morbidity length of stay, 3) individual social factors, 4) hospital characteristics, and 5) ecologic factors (region of state, percent black and Medicaid annual discharges, and mean income of admitted patients). RESULTS: Following adjustment for patient age and gender, blacks had 65% higher odds for a surgical complication. Further adjustment for comorbidity and length of stay (LOS) reduced the odds substantially to 1.18. Additional adjustment for American Hospital Association hospital characteristics essentially eliminated the risk. Final adjustment for hospital ecologic variables reduced the odds to 1.0. CONCLUSIONS: Higher rates of surgical complications among blacks than whites in NYS are primarily explained by differences in comorbidity LOS and the hospital where the surgery occurred.

Black People↗

PubMed2005

Racial disparities in the content of primary care office visits.

BACKGROUND: Little is known about racial disparities in primary care at the level of the office visit. OBJECTIVE: To assess racial disparities in the receipt of commonly performed/recommended procedures during routine primary care office visits and examine trends in disparities over time. DESIGN, SETTING, AND PATIENTS: The sample included 88,303 visits by adults to 3,260 primary care physicians in office-based practices in the National Ambulatory Medical Care Surveys, 1985, 1989, 1990, 1991, 1992, and 1995 to 2001. MEASUREMENTS: Adjusted odds for receipt or recommendation of commonly performed office procedures. RESULTS: During the years 1985 to 2001, African Americans, compared with whites, had lower odds of receiving a Pap test (odds ratio (OR) 0.81; 95% confidence interval (CI) 0.70 to 0.93), rectal exam (OR 0.67; 95% CI 0.56 to 0.80), smoking cessation counseling (OR 0.80; 95% CI 0.66 to 0.96), and mental health advice (OR 0.51; 95% CI 0.38 to 0.69), but had higher odds for visual screening (OR 1.38; 95% CI 1.08 to 1.77), weight advice counseling (OR 1.27; 95% CI 1.13 to 1.44) and receiving a follow-up appointment (OR 1.45; 95% CI 1.29 to 1.64). These findings were not appreciably altered by adjustment for physician practice characteristics including percent African American or Medicaid patients. Disparities disfavoring African Americans in cholesterol testing and smoking cessation observed during 1985 to 1992 were not observed in 1995 to 2001. CONCLUSIONS: The findings suggest that race is associated with the type of primary care received by patients, at least for selected procedures, with evidence that some disparities have diminished over time.

Black or African American↗

PubMed2005

Is patient HMO insurance or physician HMO participation related to racial disparities in primary care?

OBJECTIVE: To examine the relationship between racial disparities in common primary care procedures and patient HMO membership and physician level of HMO participation. DESIGN: Cross-sectional analysis. METHODS: Data were obtained from a nationally representative sample of primary care office visits documented in the National Ambulatory Medical Care Survey for 1985, 1989-1992, and 1997-2000. Patient HMO membership was assessed based on reports by primary care physicians (defined as family physicians/general practitioners, internists, or obstetrician-gynecologists). Physician HMO participation was assessed based on the proportion of the physician's patients who were in an HMO. Patient characteristics (age, sex, race, insurance, diagnoses) and office procedures or interventions were determined by examining the physician report. Patients were adults aged 19 years or older. RESULTS: In adjusted analyses, African Americans, compared with whites, had lower odds of receiving a Pap test (adjusted odds ratio [AORI = 0.76; 95% confidence interval [CI] = 0.65, .90), a rectal exam (AOR = 0.67; 95% CI = 0.54, 0.84), smoking cessation advice (AOR = 0.72; 95% CI = 0.58, 0.91), and mental health advice (AOR = 0.46; 95% CI = 0.29, 0.72), but had higher odds of receiving advice on diet and weight, and a follow-up appointment. Notably, there were no significant interactions between either patient HMO membership or physician level of HMO participation, patient race, and receipt of primary care services. CONCLUSION: Neither patient HMO membership nor physician level of HMO participation is substantially associated with racial disparities in primary care.

Adult↗

PubMed2004

Estimating racial/ethnic disparity in mammography rates: it all depends on how you ask the question.

BACKGROUND: Estimates of racial disparity in mammography appear to differ depending on the data source. This study examined the impact of different survey methodology on estimates of racial disparity in mammography. METHODS: Responses from 3,090 women > or =40 years to two different questions from the 1996 Medical Expenditure Panel Survey (MEPS) were compared when a mammogram was last obtained versus what medical services, including mammography, were obtained over a 4-month interval, aggregated across 1 year. RESULTS: There was no significant racial disparity in 1-year mammography prevalence based on the first question (white-black difference, 3.3%; 95% confidence interval [CI], -2.5, 9.2). In contrast, a significant disparity in 1-year mammography prevalence was found based on the medical services question (difference, 13.1%; 95% CI 8.6, 17.6). Disparity estimates by Hispanic ethnicity were similar for the two questions: white-Hispanic difference, 1.6%; 95% CI -4.3, 7.5, and white-Hispanic difference 5% (-0.2, 10.1). Adjustment for age, income, and insurance did not alter these findings. CONCLUSIONS: Estimates of racial, but not ethnic, disparities in mammography seem to depend on how the question is asked. These results caution against exclusive reliance on annual self-reports for monitoring disparities in preventive care.

Adult↗

PubMed2004

Patient trust: is it related to patient-centered behavior of primary care physicians?

BACKGROUND: Patients' trust in their health care providers may affect their satisfaction and health outcomes. Despite the potential importance of trust, there are few studies of its correlates using objective measures of physician behavior during encounters with patients. METHODS: We assessed physician behavior and length of visit using audio tapes of encounters of 2 unannounced standardized patients (SPs) with 100 community-based primary care physicians participating in a large managed care organization. Physician behavior was assessed via 3 components of the Measure of Patient-Centered Communication (MPCC) scale. The Primary Care Assessment Survey (PCAS) trust subscale was administered to 50 patients from each physician's practice and to SPs. We used multilevel modeling to examine the associations between physicians' Patient-Centered Communication during the SP visits and ratings of trust by both patients and SPs. RESULTS: Component 1 of the MPCC, which explored the patient's experience of the disease and illness, was independently associated with patient's rating of trust in their physician. A I SD increase in this score was associated with 0.08 SD increase in trust (95% confidence interval 0.02-0.14). Each additional minute spent in SP visits was also independently associated with 0.01 SD increase in patient trust. (95% confidence interval 0.0001-0.02). Component 1 and visit length were also positively associated with SP trust ratings. CONCLUSIONS: Physician verbal behavior during an SP encounter is associated with trust reported by SPs and patients. Research is needed to determine whether interventions designed to enhance physicians' exploration patients' experiences of disease and illness improves trust. Key Words: physician-patient relationship, patient-centered care, trust, physician behavior

Adult↗

PubMed2004

Preventive care.

OBJECTIVE: To examine the impact of provider continuity on preventive care among adults who have a regular site of care. DESIGN: Logistic regression analyses were conducted to explore whether continuity, categorized as having no regular care, site continuity, or provider continuity, was associated with receipt of 3 preventive care services (influenza vaccination, receipt of a mammogram, and smoking cessation advice), independent of predisposing, need, and enabling factors. PARTICIPANTS: This study examined 42664 persons with private, Medicaid, Medicare, or no health insurance coverage who reported either having no site of care or being seen in a physician's office, HMO, hospital outpatient department, or other health center. SETTING: The 1996/1997 Community Tracking Study (CTS) household survey, a telephone-based survey providing a cross-sectional sample of 60446 U.S. adults aged 18 and older representing the U.S. housed, noninstitutionalized population. MEASUREMENTS AND MAIN RESULTS: After adjustment for differences in predisposing, enabling, and need factors, site continuity was associated with significant increases of 10.4% in influenza vaccinations (P =.006) and 12.6% in mammography (P =.001), and a nonsignificant increase of 5.6% in smoking cessation advice (P =.13) compared to having no regular site of care. After adjustment for these factors, provider continuity was associated with an additional improvement of 6.0% in influenza vaccinations (P =.01) and 6.2% in mammography (P =.04), and a nonsignificant increase of 2.5% in smoking cessation advice (P =.30) compared to site continuity. CONCLUSIONS: Provider continuity and site continuity are independently associated with receipt of preventive services. Compared to having no regular site of care, having site continuity was associated with increased receipt of influenza vaccination and mammography and, compared to having site continuity, having provider continuity was associated with further increases in the receipt of these two preventive services.

Adolescent↗