Time use in clinical encounters: are African-American patients treated differently?
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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. (+info)
Primary health care services provided by nurse practitioners and family physicians in shared practice.
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BACKGROUND: Collaborative practice involving nurse practitioners (NPs) and family physicians (FPs) is undergoing a renaissance in Canada. However, it is not understood what services are delivered by FPs and NPs working collaboratively. One objective of this study was to determine what primary health care services are provided to patients by NPs and FPs working in the same rural practice setting. METHODS: Baseline data from 2 rural Ontario primary care practices that participated in a pilot study of an outreach intervention to improve structured collaborative practice between NPs and FPs were analyzed to compare service provision by NPs and FPs. A total of 2 NPs and 4 FPs participated in data collection for 400 unique patient encounters over a 2-month period; the data included reasons for the visit, services provided during the visit and recommendations for further care. Indices of service delivery and descriptive statistics were generated to compare service provision by NPs and FPs. RESULTS: We analzyed data from a total of 122 encounters involving NPs and 278 involving FPs. The most frequent reason for visiting an NP was to undergo a periodic health examination (27% of reasons for visit), whereas the most frequent reason for visiting an FP was cardiovascular disease other than hypertension (8%). Delivery of health promotion services was similar for NPs and FPs (11.3 v. 10.0 instances per full-time equivalent [FTE]). Delivery of curative services was lower for NPs than for FPs (18.8 v. 29.3 instances per FTE), as was provision of rehabilitative services (15.0 v. 63.7 instances per FTE). In contrast, NPs provided more services related to disease prevention (78.8 v. 55.7 instances per FTE) and more supportive services (43.8 v. 33.7 instances per FTE) than FPs. Of the 173 referrals made during encounters with FPs, follow-up with an FP was recommended in 132 (76%) cases and with an NP in 3 (2%). Of the 79 referrals made during encounters with NPs, follow-up with an NP was recommended in 47 (59%) cases and with an FP in 13 (16%) (p < 0.001). INTERPRETATION: For the practices in this study NPs were underutilized with regard to curative and rehabilitative care. Referral patterns indicate little evidence of bidirectional referral (a measure of shared care). Explanations for the findings include medicolegal issues related to shared responsibility, lack of interdisciplinary education and lack of familiarity with the scope of NP practice. (+info)
Using automated medical records for rapid identification of illness syndromes (syndromic surveillance): the example of lower respiratory infection.
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BACKGROUND: Gaps in disease surveillance capacity, particularly for emerging infections and bioterrorist attack, highlight a need for efficient, real time identification of diseases. METHODS: We studied automated records from 1996 through 1999 of approximately 250,000 health plan members in greater Boston. RESULTS: We identified 152,435 lower respiratory infection illness visits, comprising 106,670 episodes during 1,143,208 person-years. Three diagnoses, cough (ICD9CM 786.2), pneumonia not otherwise specified (ICD9CM 486) and acute bronchitis (ICD9CM 466.0) accounted for 91% of these visits, with expected age and sex distributions. Variation of weekly occurrences corresponded closely to national pneumonia and influenza mortality data. There was substantial variation in geographic location of the cases. CONCLUSION: This information complements existing surveillance programs by assessing the large majority of episodes of illness for which no etiologic agents are identified. Additional advantages include: a) sensitivity, uniformity and efficiency, since detection of events does not depend on clinicians' to actively report diagnoses, b) timeliness, the data are available within a day of the clinical event; and c) ease of integration into automated surveillance systems. These features facilitate early detection of conditions of public health importance, including regularly occurring events like seasonal respiratory illness, as well as unusual occurrences, such as a bioterrorist attack that first manifests as respiratory symptoms. These methods should also be applicable to other infectious and non-infectious conditions. Knowledge of disease patterns in real time may also help clinicians to manage patients, and assist health plan administrators in allocating resources efficiently. (+info)
On the relationship between the efficiency and the quality of the consultation. A validity study.
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OBJECTIVES: The aim of this study was to determine how the medical performance of physicians during consultations is related to doctor-patient communication and satisfaction of patients, taking into account the actual length of the consultations. In addition, we studied the validity of the 'efficiency-per-time score' as a measure of competence. METHODS: General practice trainees participated in a test situation in which they were confronted with six consultations with standardized (simulated) patients (SPs). All consultations were videotaped and evaluated by multiple observers, using national guidelines on medical content and on communication. The SPs scored satisfaction with the consultation using a satisfaction checklist. Forty GP-trainees were invited, of whom 34 participated. The main outcome measures were the number of obligatory actions undertaken by the GP-trainees, total number of actions undertaken, consultation time, efficiency-per-time score, patient satisfaction and quality of communication score, and the Pearson correlations between these measures. RESULTS: There was a negative correlation between the 'efficiency-per-time score' of the GP-trainees and the satisfaction of the SPs in five of the six consultations [Pearson r from -0.29 (P < 0.05) to -0.58 (P < 0.001)] and between the 'efficiency-per-time score' and the quality of the communication in three of the six consultations [Pearson r from -0.34 (P <.05) to -0.51 (P < 0.001)]. CONCLUSIONS: Short consultations with high technical medical efficiency seem to be related to bad communication and dissatisfied patients, thus questioning the validity of the 'efficiency-per-time score' as a measure of competence. (+info)
Spousal bereavement--implications for health.
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BACKGROUND: Bereavement is a potential medical problem as it has implications for health through possible associations with morbidity and mortality. OBJECTIVE: The aim of the present study was to ascertain if spousal bereavement is associated with physical and psychological parameters of illness. METHODS: A spousal bereavement register was created at a village general practice in the West Midlands of 122 spouses (4.9% of the practice population). After exclusion of 22, a sample of 100 had their medical records analysed for the periods of 12 months before and after bereavement. RESULTS: Between these two periods, the average number of consultations increased from 5.99 to 7.60 (P = 0.01), where the vast majority were for physical illness. Mean number of prescriptions increased from 8.54 to 9.15 per patient (P = 0.8) for physical illness and from 0.76 to 1.34 (P = 0.09) for psychological illness. CONCLUSION: Bereavement can be viewed as a medical problem, but this is not borne out in prescribing and so care should be taken not to over-medicalize grief. (+info)
The incidence, natural history and associated outcomes of influenza-like illness and clinical influenza in Italy.
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OBJECTIVES: This study investigated the epidemiology, natural history and resource use associated with influenza in the general population setting in Italy. METHODS: For a 3-month winter epidemic period, 202 GPs reported daily the number of visits performed for influenza-like illness (ILI), clinical influenza and any other cause. In addition, the first 10 cases of clinical influenza requiring a doctor's visit in each month of the 3-month period and for a total of 30 cases per GP were recorded carefully and followed-up, for evaluation of clinical evolution, associated outcomes and resource use. RESULTS: Almost 200 000 visits were performed by 202 GPs, ILI and clinical influenza accounting for 13.8 and 8.3% of all-cause visits, respectively. A total of 6057 cases of clinical influenza were also recorded and evaluated for associated outcomes and resource use. Twenty percent of the patients were at risk because they were elderly (>65 years) or presented with concomitant chronic conditions. Almost all the patients received at least one prescription for symptomatic drugs and 36% received a prescription for antibiotics. Thirty-five percent of patients had at least one complication from influenza, primarily upper and lower respiratory tract bacterial infections. At-risk patients had a significantly higher complication rate (odds ratio = 2.89) and required more instrumental exams and hospitalizations compared with the general population, accounting for most of the direct costs associated with clinical influenza. Patients with clinical influenza had an average of 5 days absence from work or school. CONCLUSIONS: Influenza is associated with significant morbidity in the general and at-risk population, a high degree of resource use in the at-risk population and substantial reduction or loss of productivity in the active working Italian population. (+info)
The purpose of the general practice consultation from the patient's perspective--theoretical aspects.
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BACKGROUND: Medical practice and research are paying increasing attention to what patients want, as reflected by the growth of routine surveys of patients' satisfaction and more formal studies of patients' views of medical care. However, the field lacks conceptual clarity. OBJECTIVES: The aim of this study was to propose a theoretical clarification of the concept of the patients' purpose of a consultation by presenting a patient-centred definition, applicable for clinical work and research in general practice. METHODS: An extensive literature review was conducted to explore presumptions and definitions reported by previous studies. Most authors failed to define or distinguish the concept under investigation. We took these shortcomings as our starting point, added some significant dimensions drawn from a few selected authors who had discussed relevant perspectives in their work and arrived at a proposed working definition of the 'purpose' concept. RESULTS: The proposed definition allows for multiple purposes for the consultation. We incorporate what the patient hopes to gain from the consultation, as opposed to their 'expectations of the most likely outcome'. Our working definition aims to identify patients' a priori wishes and hopes for a specific process and outcome, while acknowledging that these may not be voiced and may be modified by the patient during the consultation. General characteristics of the doctor, such as being considerate or professionally skillful, are not included. (+info)
Economic advantage of a community-based malaria management program in the Brazilian Amazon.
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In the Brazilian Amazon, travel costs to centralized malaria clinics for diagnosis and treatment can approach 20% of one's monthly salary. A program was established in a mining town for community-based dipstick test diagnosis and treatment. An economic analysis was performed that compared expected costs under the old program to the observed costs of the new one. Data were obtained through interviews, government reports, clinic and hospital records, and community records. There was a 53% reduction (by 1,219 visits) of clinic visits but a doubling of malaria hospitalization admissions (to 191). The new program had an overall annual savings of $60,900 ($11.8K-$160K, sensitivity limits), a 77% reduction of the old program's cost. The benefit-to-cost ratio was 9:1, where benefits were patients' savings from travel and lost wages and costs were government drug, diagnostic, training, and monitoring expenses. A community-based program incorporating dipstick tests for malaria management can have economic advantages. (+info)