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ABSTRACT: Our goal was to identify physician and patient characteristics associated with patient-centered beliefs about the sharing of information and power, and to determine how these beliefs and the congruence of beliefs between patients and physicians affect patients' evaluations.
Physicians completed a scale assessing their beliefs about sharing information and power, and provided demographic information. A sample of their patients filled out the same scale and made evaluations of their physicians before and after a target visit.
Physicians and patients in a large multispecialty group practice and a group model health maintenance organization were included. Forty-five physicians in internal medicine, family practice, and cardiology participated, as well as 909 of their patients who had a significant concern.
Trust in the physician was measured previsit, and visit satisfaction and physician endorsement were measured immediately postvisit.
Among patients, patient-centered beliefs (a preference for information and control) were associated with being women, white, younger, more educated, and having a higher income; among physicians these beliefs were unrelated to sex, ethnicity, or experience. The patients of patient-centered physicians were no more trusting or endorsing of their physicians, and they were not more satisfied with the target visit. However, patients whose beliefs were congruent with their physicians' beliefs were more likely to trust and endorse their physicians, even though they were not more satisfied with the target visit.
The extent of congruence between physicians' and patients' beliefs plays an important role in determining how patients evaluate their physicians, although satisfaction with a specific visit and overall trust may be determined differently.
The Journal of family practice 01/2002; 50(12):1057-62. · 0.61 Impact Factor
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ABSTRACT: The high cost of caring for patients with congestive heart failure (CHF) results primarily from frequent hospital readmissions for exacerbations. Home nurse visits after discharge can reduce readmissions, but the intervention costs are high.
To compare the effectiveness of three hospital discharge care models for reducing CHF-related readmission charges: 1) home telecare delivered via a 2-way video-conference device with an integrated electronic stethoscope; 2) nurse telephone calls; and 3) usual outpatient care.
One-year randomized trial.
English-speaking patients 40 years of age and older with a primary hospital admission diagnosis of CHF.
Our primary outcome was CHF-related readmission charges during a 6-month period after randomization. Secondary outcomes included all-cause readmissions, emergency department (ED) visits, and associated charges.
Thirty-seven subjects were randomized: 13 to home telecare, 12 each telephone care and 12 to usual care. Mean CHF-related readmission charges were 86% lower in the telecare group ($5850, SD $21,094) and 84% lower in the telephone group ($7320, SD $24,440) than in the usual care group ($44,479, SD $121,214). However, the between-group difference was not statistically significant. Both intervention groups had significantly fewer CHF-related ED visits (P = 0.0342) and charges (P = 0.0487) than the usual care group. Trends favoring both interventions were noted for all other utilization outcomes.
Substantial reductions in hospital readmissions, emergency visits, and cost of care for patients with CHF might be achieved by widespread deployment of distance technologies to provide posthospitalization monitoring. Home telecare may not offer incremental benefit beyond telephone follow-up and is more expensive.
Medical Care 12/2001; 39(11):1234-45. · 3.41 Impact Factor
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ABSTRACT: Our purpose was to explore why women are more likely than men to be diagnosed as depressed by their primary care physician. Women were found to have more depressive symptoms as self-reported on the Beck Depression Inventory (BDI). Women having high BDI scores (reflecting significant depression) were more likely than men with high BDI scores to be diagnosed by their primary care physician (p = 0.0295). Female patients made significantly more visits to the clinic than men. For both sexes, patients with greater numbers of primary care clinic visits were more likely to be diagnosed as depressed. Logistic regression revealed that gender has both a direct and indirect (through increased use) effect on the likelihood of being diagnosed as depressed. Patient BDI score, clinic use, educational level, and marital status were all significantly related to the diagnosis of depression. Controlling all other independent variables, women were 72% more likely than men to be identified as depressed, but this effect did not achieve statistical significance (p = 0.0981). In gender-specific analyses, BDI and clinic use were again significantly related to the diagnosis of depression for both sexes. However, educational and marital status predicted depression diagnosis only for women. Separated, divorced, or widowed women were almost five times as likely to be diagnosed as depressed as those who were never married, all other factors being equal. Clinic use and BDI scores were found to be important correlates of the diagnosis of depression. There was some evidence of possible gender bias in the diagnosis of depression.
Journal of Women s Health & Gender-Based Medicine 10/2001; 10(7):689-98.
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ABSTRACT: To examine patient, physician, and health care system characteristics associated with unvoiced desires for action, as well as the consequences of these unspoken requests.
Patient surveys were administered before, immediately after, and 2 weeks after outpatient visits in the practices of 45 family practice, internal medicine, and cardiology physicians working in a multispecialty group practice or group model health maintenance organization. Data were collected at the index visit from 909 patients, of whom 97.6% were surveyed 2 weeks after the outpatient visit. Before the visit, patients rated their trust in the physician, health concerns, and health status. After the visit, patients reported on various types of unexpressed desires and rated their visit satisfaction. At follow-up, patients rated their satisfaction, health concerns, and health status, and also described their postvisit health care use. Evaluations of the visit were also obtained from physicians.
Approximately 9% of the patients had 1 or more unvoiced desire(s). Desires for referrals (16.5% of desiring patients) and physical therapy (8.2%) were least likely to be communicated. Patients with unexpressed desires tended to be young, undereducated, and unmarried and were less likely to trust their physician. Patients with unvoiced desires evaluated the physician and visit less positively; these encounters were evaluated by physicians as requiring more effort. Holding an unvoiced desire was associated with less symptom improvement, but did not affect postvisit health care use.
Patients' unvoiced needs affect patients' and physicians' visit evaluations and patients' subjective perceptions of improvement. Implications of these findings for clinical practice are examined.
Archives of Internal Medicine 10/2001; 161(16):1977-84. · 11.46 Impact Factor
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ABSTRACT: Physician referral patterns significantly impact costs, quality of care, and access to the health system. This paper examines factors predictive of patient referrals to specialists by primary care residents.
New adult patients (n=509) were randomly assigned to primary care residents at a university medical center. Patient referrals to specialists were monitored for 1 year of care. Self-reported patient health status, sociodemographic information, number of primary care visits, and physician practice style behaviors were incorporated into statistical analyses predicting specialty referrals.
Patients who were referred to specialty care were significantly older, had poorer physical health, and saw their primary care physicians more often than patients who were not referred. Patients were most frequently referred to surgical specialty clinics. After controlling for physical health status, gender, and age, more frequent visits to a primary care resident physician who had a technically oriented style of care was associated with a greater total number of specialty clinic referrals.
Patient variables, as well as physician practice style, have an important impact on the specialty referral process. Although the appropriateness of referrals was not evaluated, these findings have implications for health care delivery.
Family medicine 04/2001; 33(3):203-9. · 1.33 Impact Factor
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ABSTRACT: The number of US residents with limited English proficiency (LEP) is 14 million and rising. The goal of this study was to estimate the effects of LEP on physician time and resource use.
This was a prospective, observational study.
The study included 285 Medicaid patients speaking English (n = 112), Spanish (n = 62), or Russian (n = 111) visiting the General Medicine and Family Practice Clinics at the UC Davis Medical Center in 1996-1997 (participation rate, 85%). Bilingual research assistants administered patient questionnaires, abstracted the medical record, and conducted detailed time and motion studies.
We used seemingly unrelated regression models to evaluate the effect of language on visit time, controlling for patient demographics and health status, physician specialty, visit type, and resident involvement in care. We also estimated the effect of LEP on cross-sectional utilization of health care resources and adherence to follow-up with referral and testing appointments.
The 3 language groups differed significantly by age, education, and reason for visit but not gender, number of active medical conditions, physical functioning, or mental health. Physician visit time averaged 38+/-20 minutes (mean+/-SD). Compared with English-speaking patients and after multivariate adjustment, Spanish and Russian speakers averaged 9.1 and 5.6 additional minutes of physician time, respectively (P <0.05). The language effect was confined largely to follow-up visits with resident physicians (house staff). Compared with English speakers, Russian speakers had more referrals (P = 0.003) and Spanish speakers were less likely to follow-up with recommended laboratory studies (P = 0.031).
In these academic primary care clinics, some groups of patients using interpreters required more physician time than those proficient in English Additional reimbursement may be needed to ensure continued access and high-quality care for this special population.
Medical Care 07/2000; 38(7):728-38. · 3.41 Impact Factor
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ABSTRACT: Studies have shown that women use more health care services than men. We used important independent variables, such as patient sociodemographics and health status, to investigate gender differences in the use and costs of these services.
New adult patients (N = 509) were randomly assigned to primary care physicians at a university medical center. Their use of health care services and associated charges were monitored for 1 year of care. Self-reported health status was measured using the Medical Outcomes Study Short Form-36 (SF-36). We controlled for health status, sociodemographic information, and primary care physician specialty in the statistical analyses.
Women had significantly lower self-reported health status and lower mean education and income than men. Women had a significantly higher mean number of visits to their primary care clinic and diagnostic services than men. Mean charges for primary care, specialty care, emergency treatment, diagnostic services, and annual total charges were all significantly higher for women than men; however, there were no differences for mean hospitalizations or hospital charges. After controlling for health status, sociodemographics, and clinic assignment, women still had higher medical charges for all categories of charges except hospitalizations.
Women have higher medical care service utilization and higher associated charges than men. Although the appropriateness of these differences was not determined, these findings have implications for health care.
The Journal of family practice 03/2000; 49(2):147-52. · 0.61 Impact Factor
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ABSTRACT: To explore resident physician-patient interaction in primary care to address issues relevant to quality of care for older people.
A sample of 509 new, adult, nonpregnant patients was assigned to the care of second- and third-year residents in primary care clinics. Care was compared for three subgroups of patients: older patients (65 years or older; n = 45), those aged 18 to 44 years (n = 320), and those aged 45 to 64 years (n = 144).
Observations were made at the family medicine and general internal medicine clinics at the University of California, Davis.
Self-report by means of the Medical Outcomes Study Short Form-36 (MOS SF-36) was used to determine patient demographics and patient health status. Two measures of satisfaction were obtained gauging reaction to medical care in general and to the videotaped visit specifically. Videotapes were coded for content using the Davis Observation Code.
Self-reported health status of older persons was poorer than that of younger groups as measured by the MOS SF-36. Differences in demographics were explored and then controlled, along with physical health status in subsequent analyses. Supporting prior studies, this study found that older patients had more return visits and reported higher levels of satisfaction than did younger comparison groups. Contrary to prior literature, older patients were found to have longer visits than did younger cohorts. The physician-patient interaction was significantly different in many areas between these three groups. Whereas older patients experienced more chatting in their visits, they were given less counseling, asked fewer questions, had less discussion about their families and their use of substances, were asked to change their health behavior habits less often, and were given less health education. For older patients, more of each visit was spent checking on compliance with earlier treatment and developing treatment plans.
These results provide a new and more detailed view of how resident physician-patient interaction differs between older and younger groups and raise important issues on whether quality of care needs for this population are being adequately addressed, particularly regarding mental health issues.
Journal of the American Geriatrics Society 02/2000; 48(1):30-5. · 3.74 Impact Factor
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ABSTRACT: Many patients with upper gastrointestinal (GI) bleeding have a benign outcome and could receive less intensive and costly care if accurately identified. We sought to determine whether early endoscopy performed shortly after admission in the emergency department could significantly reduce the health care use and costs of caring for patients with nonvariceal upper GI bleeding without adversely affecting the clinical outcome.
All eligible patients with upper GI bleeding and stable vital signs were randomized after admission to undergo endoscopy in 1 to 2 days (control) or early endoscopy in the emergency department. Patients with low-risk findings on early endoscopy were discharged directly from the emergency department. Clinical outcomes and costs were prospectively assessed for 30 days.
We randomized 110 consecutive stable patients with nonvariceal upper GI bleeding during the 12-month study period. The baseline demographic features, endoscopic findings, and the clinical outcomes were no different between the two groups. However the findings of the early endoscopy allowed us to immediately discharge 26 of 56 (46%) patients randomized to that group. No patient discharged from the emergency department suffered an adverse outcome. The hospital stay (median of 1 day [interquartile range of 0 to 3 days] vs. 2 days [interquartile range of 2 to 3 days], p = 0.0001) and the cost of care ($2068 [interquartile range of $928 to $3960] versus $3662 [interquartile range of $2473 to $7280], p = 0.00006) were significantly less for the early endoscopy group.
Early endoscopy performed shortly after admission in the emergency department safely triaged 46% of patients with nonvariceal upper GI bleeding to outpatient care, which significantly reduced hospital stay and costs.
Gastrointestinal Endoscopy 01/2000; 50(6):755-61. · 4.88 Impact Factor
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ABSTRACT: This paper examines the practice style patterns of family practice and internal medicine residents for established patient visits.
New adult patients (n = 509) were prospectively and randomly assigned to family practice or internal medicine clinics at a university medical center and followed for 1 year of care by resident physicians. Initial and return visits were videotaped, and physician practice styles were analyzed using the Davis Observation Code (DOC).
Resident physicians' practice styles with established patients during return visits were associated with various factors, depending on the DOC cluster of behaviors studied. These factors include patient gender, age, income, physical and mental health status, level of pain, number of return visits, and physician practice style displayed during the initial encounter. Family practice return visits had a greater emphasis on preventive services and counseling, compared with internal medicine return visits. Internists spent more visit time using technically oriented behaviors.
Patient variables, as well as baseline physician behavior, have an important influence on physician practice styles during return patient visits. There are measurable differences in the established practice styles between family practice and internal medicine resident physicians, which may reflect differences in professional training programs.
Family medicine 04/1999; 31(3):187-94. · 1.33 Impact Factor
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ABSTRACT: There are differences in styles of care among primary care physicians. The purpose of our study was to determine whether differences in physician practice styles and patient health status generate different medical charges.
New adult patients (N = 509) were randomized to primary care physicians, and use of medical care services and associated charges were monitored for 1 year.
Controlling for baseline patient health status, a technically oriented style of care was associated with significantly higher specialty care, emergency department, diagnostic, and total charges. Some practice behaviors, however, were associated with lower charges; for example, a practice style emphasizing patient activation was associated with significantly lower primary care charges. Both a lower baseline patient health status and a health status that declined over the study period predicted higher charges.
Measurable differences in practice style are associated with differing medical care charges. Patients' health status was also an important determinant of medical charges and had implications for the assessment of physician utilization patterns.
The Journal of family practice 02/1999; 48(1):31-6. · 0.61 Impact Factor
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ABSTRACT: This study compared patient health status, patient satisfaction, and physician practice style between family practice and internal medicine.
New adult patients (n = 509) were prospectively and randomly assigned to family practice or internal medicine clinics at a university medical center and followed for 1 year of care. Practice styles were characterized by the Davis Observation Code. Self-reported health status (Medical Outcomes Study, Short Form-36) and patient satisfaction also were measured.
There were no significantly different changes in self-reported health status or patient satisfaction between family practice and internal medicine physicians during the course of the study. Family practice initial encounters, however, were characterized by a style placing greater relative emphasis on health behavior and counseling, whereas internists used a more technical style. Improved health status scores after treatment were predicted by a practice style emphasis on counseling, whereas improvements in patient satisfaction scores were predicted by a style of care stressing patient activation. Although this is the first known randomized trial studying this issue, the conclusions are limited by a 38% loss of patients from enrollment to care and a loss of 18% at the 1-year follow-up evaluation.
There were significant differences in practice styles between family physicians and internists; however, it was the physician's behavior, not specialty per se, that affected patient outcomes. A practice style emphasizing psychosocial aspects of care was predictive of improvements in patient health status, whereas a practice style emphasizing patient activation was predictive of improvements in patient satisfaction.
Medical Care 07/1998; 36(6):879-91. · 3.41 Impact Factor
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ABSTRACT: Recognition of depression in primary care is both important and difficult. To study recognition of depression, we monitored care delivered to new adult patients randomly assigned to primary care providers.
At study entry, 508 patients completed the Beck Depression Inventory (BDI) and the Medical Outcomes Study Short-form Health Survey-36 (SF-36), a measure of health status. Chart notes were reviewed at the end of 1 year.
Only 36 of 130 patients with elevated BDI scores > or = 9 (moderate-to-severe depression) were noted as depressed on the chart. Patient characteristics predicting chart notation of depression included BDI scores, health status, gender, and education. When controlling for these factors, neither age nor race were statistically significant in the prediction of the recognition of depression. Female patients were more likely to be diagnosed as depressed than men with comparable BDI and SF-36 scores. Greater patient education was associated with enhanced likelihood of diagnosis of depression. Both BDI scores and health status were important predictors of diagnosis of depression. All SF-36 subscales correlated highly with BDI scores, suggesting that these measures may lack adequate discriminant validity.
Identifying diagnostic tendencies may help primary care providers improve detection of depression, a critical first step toward effective management.
Family medicine 04/1997; 29(3):172-6. · 1.33 Impact Factor
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ABSTRACT: Depression is common but not well diagnosed in primary care medicine. This study examines the influence of depression and its recognition on the physician-patient encounter.
A total of 508 new adult patients were assigned randomly to 105 primary care providers. Self-reported depression was determined by the Beck Depression Inventory (BDI) on entry to the study. Initial visits were videotaped and analyzed using the Davis Observation Code. Chart notes were reviewed for diagnosis of depression.
Seventy-seven of the 508 study patients (15%) were identified as depressed in chart notes, while 130 patients (26%) had a BDI score > or = 9, indicating moderate to severe depression. Recognition of depression was associated with increased counseling, decreased time conducting physical examination, and an increase in overall visit length. Both elevated BDI scores and physician recognition of depression were associated with decreases in chatting. Failure to recognize depression was associated with increased time taking medical history.
Results support the potential value of psychological screening instruments in primary care and provide information for training physicians in the recognition and management of depression. The content of office visits is different when patients are depressed or are diagnosed as depressed.
Family medicine 05/1996; 28(5):346-51. · 1.33 Impact Factor
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ABSTRACT: As more women enter medicine, intriguing questions arise about how physician gender impacts practice style. To measure this influence in primary care encounters, 118 male and 132 female adult new patients, having no stated preference for a specific physician, were randomly assigned to university hospital primary care residents, and their initial encounters were videotaped. Forty-eight male and 33 female physicians participated. Patient health status was assessed before the visit with the Medical Outcomes Study Short-Form General Health Survey. Physician practice style was evaluated by using the Davis Observation Code to analyze videotapes of each initial visit. Patient satisfaction with medical care was assessed with satisfaction questionnaires. Contrary to prior reports, the difference between male and female physicians in total time spent with patients was small and statistically insignificant, and diminished further when controlling for patient gender and health status. Female physicians, however, were observed to engage in more preventive services and to communicate differently with their patients. These differences in practice style appear to explain partially the observed higher patient satisfaction scores for female physicians. This study underscores the importance of careful measurement and control of potential confounding factors in clarifying the impact of physician gender on practice style.
Medical Care 05/1995; 33(4):407-16. · 3.41 Impact Factor
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ABSTRACT: The recent development of health status measures now facilitates the study of how patient health influences physician practice style.
The health status of 150 new patients at a university primary care center was assessed using the Medical Outcomes Study Short-Form General Health Survey. Videotapes of the physician-patient encounter were analyzed with the Davis Observation Code to explore the effect of patient health status on physician practice style.
Regression analyses demonstrated that better health was predictive of a greater portion of the visit being spent on physical examination and chatting and a smaller portion of the visit on history taking. Counseling was predicted by diminished patient mental health scores. Preliminary evidence was found for different practice styles based on patient characteristics such as sex, age, education, and income.
Results suggest that the physician-patient encounter is strongly influenced by health status. It will be crucial for future studies of physician-patient interaction to include an assessment of the patient's health status.
Family medicine 10/1993; 25(8):530-5. · 1.33 Impact Factor
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ABSTRACT: Previous research on the relationship between physician behavior and patient satisfaction has not always used standardized terminology and instruments to measure physician behavior. The Davis Observation Code (DOC) provides a reliable and valid means of analyzing clinically relevant units of physician behavior. The units of behavior can then be related to patient satisfaction.
One hundred new patients randomly assigned to receive care from primary care residents at a university medical center outpatient facility were evaluated. Before seeing their physicians, patients completed a previsit questionnaire to determine their general level of satisfaction with health care. During the visit, the encounter was videotaped and physician behavior characterized using DOC. After the appointment, patients completed a visit-specific satisfaction questionnaire. Multiple regression analysis was used to model the visit-specific satisfaction variables in terms of DOC measurements.
Total visit-specific satisfaction was positively related to previsit satisfaction (P < or = .05) and to time spent on health education (P < or = .001), physical examination (P < or = .05), and discussion of treatment effects (P < or = .01). There was a negative relationship with time spent on history taking (P < or = .01). Slightly more than 25% of the variability in satisfaction was explained by these five variables (R2 = .26). The general, humaneness, and quality/competence subscales of visit-specific satisfaction were also positively related to health education, physical examination, and treatment effects and negatively related to history taking.
Patients are most satisfied with medical visits in which they talk about their specific therapeutic interventions, are examined, and receive health education. Extended general discussion of medical history is negatively related to satisfaction.
Family medicine 02/1993; 25(1):17-20. · 1.33 Impact Factor
