Biomedical subjects

S A Flocke

Publications and source records attributed to S A Flocke.

At least 19 recordsLinked to original sources

PubMed2001

Race and preventive services delivery among black patients and white patients seen in primary care.

BACKGROUND: Numerous studies have documented racial disparities in delivery of health care treatment services, but there is little information to determine whether similar disparities exist in the delivery of preventive services. OBJECTIVE: To determine if disparities exist in preventive service delivery to non-Hispanic white patients and black patients in primary care. RESEARCH DESIGN: Multimethod study using direct observation of patient encounters, medical record review, and patient exit questionnaire. SUBJECTS: Four thousand three hundred thirteen outpatients presenting to 138 family physicians. MEASURES: Delivery of 15 screening, 24 health-habit counseling and 11 immunization services recommended by the US Preventive Services Task Force. RESULTS: Using multilevel linear regression analysis, no significant racial differences were found in rates of delivery of screening services or immunizations. However, black patients were more likely to receive preventive health-habit counseling (mean percent of patients up-to-date on all recommended counseling services, adjusted for covariates: 11.6% for black patients, 9.5% for whites, P = 0.003). CONCLUSIONS: Black patients able to access primary care receive preventive services at rates equal to or greater than white patients. This suggests that efforts to increase delivery of preventive care in black patients need to focus on access to primary care.

Adolescent↗

PubMed2001

Care of the secondary patient in family practice. A report from the Ambulatory Sentinel Practice Network.

BACKGROUND: Care of a secondary patient (an individual other than the primary patient for an outpatient visit) is common in family practice, but the content of care of this type of patient has not been described. METHODS: In a cross-sectional study, 170 volunteer primary care clinicians in 50 practices in the Ambulatory Sentinel Practice Network reported all occurrences of care of a secondary patient during 1 week of practice. These clinicians reported the characteristics of the primary patient and the secondary patient and the content of care provided to the secondary patient. Content of care was placed in 6 categories (advice, providing a prescription, assessment or explanation of symptoms, follow-up of a previous episode of care, making or authorizing a referral, and general discussion of a health condition). RESULTS: Physicians reported providing care to secondary patients during 6% of their office visits. This care involved more than one category of service for the majority of visits involving care of a secondary patient. Advice was provided during more than half the visits. A prescription, assessment or explanation of symptoms, or a general discussion of condition were provided during approximately 30% of the secondary care visits. Secondary care was judged to have substituted for a separate visit 60% of the time, added an average of 5 minutes to the visit, and yielded no reimbursement for 95% of visits. CONCLUSIONS: Care of a secondary patient reflects the provision of potentially intensive and complex services that require additional time and are largely not reimbursed or recognized by current measures of primary care. This provision of secondary care may facilitate access to care and represent an added value provided by family physicians.

Adolescent↗

PubMed2001

Addressing multiple problems in the family practice office visit.

OBJECTIVES: The purpose of the study was to describe the number of problems addressed during family practice outpatient visits, the nature of additional problems raised, how they affect the duration of the visit, and how well they are reflected in the billing record. STUDY DESIGN: Cross-sectional. POPULATION: We studied a total 266 randomly selected adult patient encounters representing 37 physicians. OUTCOMES MEASURED: A problem was defined as an issue requiring physician action in the form of a decision, diagnosis, treatment, or monitoring. Visit duration and the number of billing diagnoses were also assessed. RESULTS: On average, 2.7 problems and 8 physician actions were observed during an encounter. More than one problem was addressed during 73% of the encounters; 36% of these additional problems were raised by the physician and 58% by the patient. On average, each additional problem increased the length of the visit by 2.5 minutes (P<.001). The concordance between the number of problems observed and the number of problems on the billing sheet indicated a trend toward underbilling the number of problems addressed. CONCLUSIONS: Multiple problems are commonly addressed during family practice outpatient visits and are raised by both the physicians and the patients. Our findings suggest that current views of physician productivity and the billing record are poor indicators of the reality of providing primary care.

Adult↗

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↗

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

Does managed care restrictiveness affect the perceived quality of primary care? A report from ASPN. Ambulatory Sentinel Practice Network.

BACKGROUND: The competitive managed care marketplace is causing increased restrictiveness in the structure of health plans. The effect of plan restrictiveness on the delivery of primary care is unknown. Our purpose was to examine the association of the organizational and financial restrictiveness of managed care plans with important elements of primary care, the patient-clinician relationship, and patient satisfaction. METHODS: We conducted a cross-sectional study of 15 member practices of the Ambulatory Sentinel Practice Network selected to represent diverse health care markets. Each practice completed a Managed Care Survey to characterize the degree of organizational and financial restrictiveness for each individual health care plan. A total of 199 managed care plans were characterized. Then, 1475 consecutive outpatients completed a patient survey that included: the Components of Primary Care Instrument as a measure of attributes of primary care; a measure of the amount of inconvenience involved with using the health care plan; and the Medical Outcomes Study Visit Rating Form for assessing patient satisfaction. RESULTS: Clinicians' reports of inconvenience were significantly associated (P < .001) with the financial and organizational restrictiveness scores of the plan. There was no association between plan restrictiveness and patient report of multiple aspects of the delivery of primary care or patient satisfaction with the visit. CONCLUSIONS: Plan restrictiveness is associated with greater perceived hassle for clinicians but not for patients. Plan restrictiveness seems to be creating great pressures for clinicians, but is not affecting patients' reports of the quality of important attributes of primary care or satisfaction with the visit. Physicians and their staffs appear to be buffering patients from the potentially negative effects of plan restrictiveness.

Adult↗

PubMed1998

Etiology and diagnosis of bilateral leg edema in primary care.

PURPOSE: To identify the causes of bilateral leg edema in a primary care setting, and to determine the ability of primary care providers to arrive at the correct diagnosis using the information available at the initial clinical encounter. PATIENTS AND METHODS: Fifty-eight ambulatory adult patients with bilateral leg edema were enrolled at an inner city family practice during a 3-year period. Historical information, physical examination findings, and clinical impressions of primary care providers were compared with the results of laboratory evaluations consisting of echocardiograms, venous duplex ultrasound leg scans, serum albumin levels, and when appropriate, 24-hour urinalyses. RESULTS: Forty-five patients (78%) completed the study. The initial clinical impression was venous insufficiency in 32 (71%) patients and congestive heart failure in 8 (18%) patients. In actuality, 15 (33%) patients had a cardiac condition as a cause of their leg edema, and 19 (42%) had pulmonary hypertension. All of the patients with heart disease, and almost all of those with pulmonary hypertension, were age 45 years or older. Only 10 (22%) of the subjects had venous insufficiency. Renal conditions, medication use, and hypoalbuminemia were less common. CONCLUSIONS: Utilizing clinical information only, many patients with cardiopulmonary pathology were incorrectly diagnosed as having more benign conditions, most commonly venous insufficiency. Echocardiographic evaluation, including an estimation of pulmonary artery pressure, may be advisable in many patients with bilateral leg edema, especially if they are at least 45 years old.

Clinical Competence↗

PubMed1998

Critical success factors for promotion and tenure in family medicine departments.

PURPOSE: (1) To summarize the judgments of family medicine department leaders regarding the elements leading to success in promotion and/or tenure, and (2) to compare the views of department leaders with those of family medicine faculty who have been successfully promoted. METHOD: Two surveys were conducted. The first was of 296 associate professor members of the Society of Teachers of Family Medicine in November 1993. The second, conducted in the summer of 1994, was of all 115 U.S. members of the Association of Departments of Family Medicine; surveys were addressed to chairs, directors, or promotion and tenure committee chairs. Both survey instruments requested data regarding each respondent's department, impressions about the promotion and tenure processes at the respondent's institution, and general impressions regarding the characteristics of successful candidates. Comparisons of the responses to the two questionnaires were made using two-tailed t-tests; responses to open-ended questions were analyzed qualitatively by two independent investigators. RESULTS: In all, 75% of the department leaders and 67% of the associate professors returned completed questionnaires. The two groups had similar views about the importance of certain academic activities to success at promotion and tenure. The primary difference between the groups was in their estimates of weekly time available for research and writing activities: the leaders reported that successful candidates spent a mean of 25% of their work-weeks on research and writing activities; the associate professors, on the other hand, reported spending a mean of 15% of their workweeks on these activities. The department leaders described six basic groups of critical success factors. The associate professors emphasized lack of time as a major obstacle to success. CONCLUSION: The findings emphasize the critical importance of protected time for scholarly activities (such as research and writing) if generalists are to be promoted or tenured.

Career Mobility↗

PubMed1998

How valid are medical records and patient questionnaires for physician profiling and health services research? A comparison with direct observation of patients visits.

OBJECTIVES: This study was designed to determine the optimal nonobservational method of measuring the delivery of outpatient medical services. METHODS: As part of a multimethod study of the content of primary care practice, research nurses directly observed consecutive patient visits to 138 practicing family physicians. Data on services delivered were collected using a direct observation checklist, medical record review, and patient exit questionnaires. For each medical service, the sensitivity, specificity, and Kappa statistic were calculated for medical record review and patient exit questionnaires compared with direct observation. Interrater reliability among eight research nurses was calculated using the Kappa statistic for a separate sample of videotaped visits and medical records. RESULTS: Visits by 4,454 patients were observed. Exit questionnaires were returned by 74% of patients. Research nurse interrater reliabilities were generally high. The specificity of both the medical record and the patient exit questionnaire was high for most services. The sensitivity of the medical record was low for measuring health habit counseling and moderate for physical examination, laboratory testing, and immunization. The patient exit questionnaire showed moderate to high sensitivity for health habit counseling and immunization and variable sensitivity for physical examination and laboratory services. CONCLUSIONS: The validity of the medical record and patient questionnaire for measuring delivery of different health services varied with the service. This report can be used to choose the optimal nonobservational method of measuring the delivery of specific ambulatory medical services for research and physician profiling and to interpret existing health services research studies using these common measures.

Adult↗

PubMed1998

The association of attributes of primary care with the delivery of clinical preventive services.

OBJECTIVES: Evidence is building that primary care is associated with quality of care and cost effectiveness. Still, little is known of the contribution of specific attributes of primary care to important health outcomes, such as the delivery of preventive services. This study tests the association of specific attributes of primary care with a comprehensive measure of the delivery of preventive services. METHODS: A cross-sectional multimethod study design was used to examine 2,889 patient visits to 138 community-based primary care physicians. Four primary care attributes were measured: patient preference for their regular physician, interpersonal communication, physician's accumulated knowledge of the patient, and coordination of care. Delivery of US Preventive Service Task Force-recommended services were based on data collected from direct observation and medical record review. Hierarchical linear regression models (HLM) were used to test the association of each of the primary care attributes with being up to date on screening, immunization, and health habit counseling preventive services. Each regression model was adjusted for patient age, race, health status, and insurance type. RESULTS: Interpersonal communication and coordination of care scale scores were associated with being more up to date on screening services and health habit counseling. Accumulated knowledge and preference for regular physician were associated with being more up to date on immunizations. CONCLUSIONS: The attributes of primary care measured in this study are associated with the receipt of preventive services. Fostering the tenets of primary care may have an impact on the delivery of preventive services and possibly other important health outcomes.

Adolescent↗

PubMed1998

The value of a family physician.

BACKGROUND: Most efforts to improve health care have been made without a full understanding of the value of a primary care approach. METHODS: This article synthesizes the observations from the Direct Observation of Primary Care (DOPC) study. This multimethod study of 138 family physicians in 84 practices included direct observation of 4454 patients visits were used to describe aspects of family practice that may provide value for patients. RESULTS: Family physicians provide and coordinate care for a wide variety of patients problems, prioritizing these competing demands on the basis of relationships developed during multiple patient visits over time. They use acute and chronic illness visits as opportunities to integrate care for specific diseases, mental health, and preventive care in ways that are tailored to the specific needs of patients and families. Higher rates of delivery of core attributes of family practice are associated with patient satisfaction and preventive services delivery, and are diminished by forced discontinuity of care. CONCLUSIONS: Family physicians prioritize and deliver care according to a broad agenda based on patient needs. These needs are understood within ongoing relationships with the patient, family, larger health care system, and community. This integrative approach includes numerous avenues for affecting important patient outcomes that are unlikely to be optimally met by less integrated models of medical care. Expanding the value of family practice will require the development and application of new knowledge of the core structures, processes, and contexts of family practice, and their effects on patient outcomes.

Cross-Sectional Studies↗

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

Trade-offs in high-volume primary care practice.

BACKGROUND: With today's emphasis on reducing costs and increasing efficiency, primary care physicians are under pressure to increase patient volume. This study was undertaken to (1) identify factors associated with differences in physician volume, and (2) test for differences in selected clinical outcomes and time use during patient visits. METHODS: Research nurses directly observed consecutive patient visits during 2 separate days in the offices of 108 community family physicians. Data on the content of 3893 outpatient visits were collected using direct observation, patient and physician questionnaires, and medical record review. Physicians with high-, medium-, and low-volume practices were compared in the rates of preventive services delivery, patient satisfaction, and time use during patient visits as measured with the Davis Observation Code. RESULTS: High-volume physicians had visits that were 30% shorter, scheduled one third fewer patients for well care, and were more likely to own their practice and to be male than were low-volume physicians. Time use during patient visits was remarkably similar for high- and low-volume physicians. However, after controlling for relevant patient characteristics, patients of high-volume physicians had lower up-to-date rates of preventive services and scored lower on measures of satisfaction and the doctor-patient relationship. CONCLUSIONS: Physicians with high-volume practices are more efficient than those with low-volume practices in providing similar services in a shorter amount of time. This greater apparent efficiency may come at a cost of lower rates of preventive services delivery, lower patient satisfaction, and a less positive doctor-patient relationship. Health care plans and physicians setting productivity goals should consider the trade-offs inherent in high-volume practice.

Adult↗

PubMed1998

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

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

Continuity of Patient Care↗

PubMed1998

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

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

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

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

Adult↗