Quality assessment of primary health care in a military setting

PURPOSE: The aim of this study was to analyze the quality of primary care in Israeli Defense Forces primary care clinics and physicians (PCPs) and to test the hypotheses that: (1) the quality of primary care provided in battalions is higher than that provided by other primary care providers and (2) the evaluation of a specific PCP within the framework of the quality assessment program results in an improved score during a second evaluation. METHODS: Teams of two physicians carried out the control process. Each primary care clinic is evaluated in a standardized manner by filling a prospectively established form. Five parameters are examined: (1) direct inspection of the PCP, (2) medical record audit, (3) high-risk patients' management evaluation, (4) evaluation of secondary health care characteristics, and (5) medical staff guidance evaluation. The various clinics and physicians evaluated were classified as: battalion clinics, division and brigade clinics, training center clinics, and home-front clinics. RESULTS: Between the years 1999 and 2001, 149 primary care clinics and 250 PCPs were evaluated. Seventy-four PCPs (29.6%) were evaluated twice. Battalion clinics scored higher than the other clinics. PCPs evaluated twice had significantly better quality assessment results at the second encounter. CONCLUSIONS: Quality of primary health care is the highest in battalion troops clinics. We interpret the increase in quality assessment scores from one examination to the other as an index of improvement resulting from the feedback given to the providers.     

The relation between good communication skills on the part of the physician and patient satisfaction in a military setting

OBJECTIVE: The objective of this study was to assess the correlation between patients' view of the consultation and the assessment of an auditing physician on the same consultation. METHODS: A prospective study in military clinics was conducted. A board-certified family physician made a real-time semistructured assessment of the medical consultation. At the end of it, the patient was asked to fill in the Consultation Satisfaction Questionnaire. The degree of correlation between patients' satisfaction from consultation and the scores given by the auditing physician was evaluated. RESULTS: Twelve primary care physicians were evaluated. A total of 117 (76.5%) of 153 patients returned their questionnaires. A positive correlation was found between physician's communication skills and general satisfaction (r = 0.614), professional care (r = 0.367), and depth of relationship (r = 0.275) calculated from the Consultation Satisfaction Questionnaire. No correlation was found between patient satisfaction and other consultation skills. CONCLUSIONS: Good communication skills may enhance patient satisfaction. It may be advisable to investigate whether a training program to enhance the physician's communication skills can improve patient satisfaction.     

Physicians' perceptions of the status of adolescent health care within the military health system.

OBJECTIVE: To describe the nature of the health care delivered to dependent adolescents throughout the military and compare services provided in adolescent medicine clinics with those provided in other medical departments and clinics. METHOD: Questionnaires were sent to physicians in pediatrics, internal medicine, family practice, primary care, emergency care, and adolescent medicine at 101 randomly selected military treatment facilities. A subsample of experts was selected to provide facility-specific, informed, representative information on the care provided to adolescents. RESULTS: Sixty-six percent (N = 345) of physicians returned completed questionnaires, providing information on 100% of the facilities sampled. More than half of responders felt that adolescents avoided care in their department. Two-thirds of all physicians, and three-fourths of the expert subsample, believed that adolescents are best served within adolescent medicine clinics. The expert subsample reported that adolescents served in facilities with adolescent medicine clinics received broader services. Only 28% of the facilities sampled provided any specialized adolescent medicine services. CONCLUSION: The military health care system has made progress in providing care to adolescent dependents, but reaching larger numbers of adolescents requires additional efforts.     

Evaluating delivery of primary health care to military personnel during low-intensity conflict using a patient satisfaction survey

The delivery of medical health care to soldiers serving in active front units in the Israeli Defense Forces requires the ability to adjust to different military activity settings. This study was conducted to compare patient satisfaction, as a tool for assessing quality of care, in different activity settings: training and Low-intensity conflict setting. A patient satisfaction survey was conducted simultaneously in battalions during low-intensity conflict and training activities. Data analysis showed that patients' perception of the quality of care they received and of medical staff attitude was higher in the conflict setting. Correlation analysis revealed that patients during conflict perceived outcome of care and accessibility as most important in evaluating overall satisfaction. We suggest that perception of high-quality medical care can be obtained during conflict conditions. Interestingly, in the conflict setting, the physical environment of the clinics appears to be less crucial to patient satisfaction than physician availability and medical outcome. These results may serve as a basis for changing health delivery systems by health policy makers.     

Provider satisfaction in army primary care clinics

The job satisfaction of physicians, nurse practitioners, and physician assistants was assessed during the course of a multicenter study of Army primary care clinics. All providers in nine clinics at three medical centers who were engaged in adult or family care were invited to participate in the study. Questionnaires on job satisfaction and other practice style variables were completed by 26 physicians, 19 nurse practitioners, and 13 physician assistants (46, 76, and 41% of eligible providers, respectively). Analysis revealed a broad range of job satisfaction in the sample. However, average levels of job satisfaction were not significantly different across the three groups of primary care providers. Autonomy and collaboration were significant predictors of job satisfaction. It is clear that changes in health care systems that reduce, or appear to reduce, the primary care provider's autonomy in clinical matters are likely to reduce provider satisfaction as well.     

Outsourcing of primary care: satisfaction level in the Israeli Defense Forces

OBJECTIVE: To examine the effect of outsourcing primary care services on satisfaction levels among career soldiers in the Israeli Defense Forces (IDF). METHODS: Data were acquired via self-administered satisfaction questionnaires during the visits of soldiers and civilians to primary care clinics in military bases, hospitals, and HMO settings. Multivariable analyses (GLM) used the SAS statistical program. RESULTS: Two hundred thirty civilians and 618 soldiers (200 in hospital clinics, 277 in military clinics, and 141 in HMO clinics) completed 848 questionnaires. Gender did not influence satisfaction level (alpha < 0.05). Age and rank influenced two parameters: surroundings (p = 0.0277) and availability of the medical service (p = 0.0368). Location (hospital clinic, HMO clinic, and military clinic) was the primary variable influencing and predicting satisfaction level (11.6%). "Quality of medical care" predicts only 4% of satisfaction level. Soldiers in HMO settings expressed a higher degree of satisfaction particularly in availability of service, quality of service, general satisfaction, and courtesy. CONCLUSIONS: Career soldiers in Israel value all aspects of primary care given by a civilian HMO and are willing to accept a change (outsourcing primary care to a civilian provider). As a result, decision makers should expand the provision of these services to all career soldiers in Israel. Outsourcing of medical services can serve as a model to military corps worldwide.     

Diagnoses, demographics, and utilization of care as encountered by three U.S. Navy general medical officers

U.S. Navy general medical officers (GMOs) are physicians serving as general practitioners. Although exceptions exist, most GMOs are not board-certified in a specialty. They are post-graduate year 1 (PGY-1)-trained, state-licensed physicians analogous to civilian general practitioners. We conducted a retrospective study using data generated from patient visits with active duty males and females from June 1 to 30, 1998, to describe diagnoses, demographics, and utilization of care patterns encountered by three PGY-1-trained GMOs at an ambulatory clinic. A total of 781 patient encounters with 123 diagnoses from a patient population of 3,178 were recorded. This is an average of 260 patient encounters per GMO, at a rate of 2.52 patients seen per patient-care hour. Fifty-seven consultations/referrals were requested (7.3% of encounters, 1.8% of the patient population). Personnel assigned to the clinic accounted for 4.2% of visits (2% of the patient population). Patient satisfaction was rated as "excellent" to "satisfactory," and no significant morbidity was observed at 1.5-year follow-up. With PGY-1 training, GMOs provide primary care to a substantial volume of prescreened patients and treat patients with a majority of diagnoses without referral or unacceptable complications. The role of GMOs, and perhaps other physicians without specialty training (i.e., general practitioners), in selected settings seems valid and may have advantageous medicoeconomic implications for military and civilian managed care systems.     

Patient satisfaction in military medicine: status and an empirical test of a model

The Department of Defense (DoD) is concerned about how well military medical treatment facilities in the military health system perform. Patient expectations, attitudes, and health care use have been examined in numerous studies; the results are fairly consistent. Eligible beneficiaries report moderate satisfaction with the health care received. In 1994-2001, annual DoD and monthly ambulatory patient surveys were conducted in military medical treatment facilities. The DoD surveys document how patients perceive the care provided. The obvious research concerns are: requirements for conducting surveys; who should be surveyed: eligible beneficiaries or actual users; when; where; representative sample; how often to conduct assessment; data collection methods; analytic schemes; overall trends; predictors of satisfaction; use of results; and timeliness of findings. This study examines these issues and analyzes raw data from selected annual DoD and monthly ambulatory surveys. The overall level of perceived satisfaction has been "good" over the years surveys were used. The model demonstrated the use of examining demographic and attitudinal components of patient satisfaction in military medical facilities.     

Nonclinical factors associated with primary care physicians’ ordering patterns of magnetic resonance imaging/computed tomography for headache

RATIONALE AND OBJECTIVES: The purpose of ordering an imaging test for headache, which is one of the most common reasons for patient consultation with a primary care physician (PCP), include medical indications as well as patient anxiety and medico-legal concerns. The impact of nonclinical factors on PCPs' ordering patterns of magnetic resonance imaging/computed tomography for patients presenting with a headache was examined. MATERIALS AND METHODS: A retrospective record review of all patients treated for headache as their primary complaint by a PCP from a multispecialty group practice associated with an 180,000-member Health Maintenance Organization during calendar year 2000 was examined. The practice included 18 clinics. Logistic regression was used to estimate the association between physician ordering patterns of imaging tests and patient, physician, and clinic setting characteristics. RESULTS: Of the total study subjects (n = 4,372), a magnetic resonance imaging/computed tomography imaging test was ordered for 5.3%. At their first encounter, patient's gender, site of care, and insurance status under the health care system's Health Maintenance Organization had statistically significant associations with the likelihood of imaging test orders. Female physicians were less likely to order an imaging test (OR = 0.65; 95% confidence interval, 0.39-1.08). For subsequent encounters, however, site of care was the only nonclinical factor that had a consistent association with the likelihood of having a magnetic resonance imaging/computed tomography ordered. CONCLUSION: These data show that a number of nonclinical factors may have been associated with having an imaging test ordered by a PCP when patients presented with a headache. These factors were more significant when the patient was being seen for the first time with this complaint.     

A psychometric comparison of military and civilian medical practices

BACKGROUND: Our purpose was to compare the psychometric properties of military and civilian ambulatory internal medicine care. METHODS: Military data came from two cohorts of patients presenting for primary care. Variables collected included mental disorders (the PRIME-MD study), previsit symptom-related concerns and expectations, functional status (Medical Outcomes Study SF-6 and SF-20 scales), postvisit unmet expectations, satisfaction with care (Medical Outcomes Study five-item survey), and physician-perceived "difficulty" (Difficult Doctor-Patient Relationship Questionnaire). This data set was compared with data abstracted from several civilian studies of ambulatory primary care. These studies used the same instruments and took place during the same period. RESULTS: Military and civilian patient populations were equally likely to have mental disorders, with no differences in the prevalence of disorders within the broad categories of mood, anxiety, somatoform, eating, or alcohol disorders. Civilian populations had a slightly higher rate of some specific diagnoses, including major depression, panic disorder, and generalized anxiety disorder. There was a similar distribution of previsit expectations of care and in the types of postvisit unmet patient expectations, with military patients having slightly lower rates of unmet expectations. Patients in both practice settings had similar self-reported ratings in the six domains of functioning (role, social, pain, emotion, physical, general health), with civilian patients reporting slightly worse overall self-rated health. Both settings had high rates of fully satisfied patients (40% "excellent" for both), with patients with unmet expectations in both groups much less likely to be fully satisfied. There was also a similar proportion of encounters rated as difficult by the clinician (military, 11%; civilian, 15%; p = 0.99). The correlates of difficulty in both groups were similar, with mental disorders and multiple symptoms increasing the likelihood of a difficult encounter. CONCLUSIONS: The psychometric properties of patient care in military and civilian internal medicine ambulatory settings are remarkably similar. These data support mutual generalizability of primary care research findings with respect to psychometric properties between military and civilian populations.     

Satisfaction among soldiers with secondary medical services within military and civilian clinical settings

The medical services system of the Israel Defense Forces (IDF) is founded on a principle that by definition considers it the military's role to maintain the health of its personnel in uniform. The 1994 Compulsory Health Insurance Law, Section 55 addresses health services for soldiers, stating that a soldier is entitled to health services from the Medical Corps of the IDF or an agent operating on its behalf. In the implementation of its responsibilities, the IDF Medical Corps operates an array of medical services, including secondary care. This study deals with the scope of utilization of secondary medical services by IDF personnel visiting military medical clinics and civilian hospital outpatient clinics: their character, the subjective health status of the respondents, and their degree of satisfaction with medical services. The results indicate that most of those seeking medical treatment at military and civilian clinics are not chronically ill. Most consider their health status to be good to excellent, but many of those referred for secondary care--more than half of the respondents who visited military specialist clinics-visited the clinics many times and even visited other clinics. No problem of access to clinics was found, but availability was problematic. There was a marked preference among patients to receive secondary health sevices from outside civilian agents rather than the military system.     

Primary care outcomes and provider practice styles

The purpose of this study was to evaluate change in patient outcomes as a function of practice styles of primary care providers. A prospective, repeated-measures, correlational design was used. Data were collected about (1) providers' self-ratings of practice styles, inclusive of practice model, confidence, autonomy, collaboration, information giving, and job satisfaction, and (2) primary care patients' self-ratings of health status, functional status, information seeking, and satisfaction. When severity and comorbidity were controlled, physicians, nurse practitioners, and physician assistants produced equivalent outcomes; neither practice style nor provider type resulted in differences in health outcomes of primary care patients. Practice style did affect patient satisfaction. Patients were least satisfied with providers who scored high on collaboration and most satisfied with providers who scored low on the practice model. Neither provider type nor interpersonal attributes had an effect on health outcomes; sicker patients got better and healthy patients stayed that way.     

Linkage between the Israeli Defense Forces primary care physician demographics and usage of secondary medical services and laboratory tests

BACKGROUND: The primary care physicians in the Israeli Defense Forces, as in the Israeli civilian health system, have two major subpopulations. Graduates of Israeli schools of medicine, and graduates of foreign medical schools, most of them in Eastern Europe. OBJECTIVE: To evaluate differences in the referral patterns of primary care physicians according to their graduation institution and demographic characteristics. METHODS: The study took place in one primary care practice in central Israel. The referrals to consultations and laboratory tests over a period of 1 year were evaluated. Physicians that had less than 37 encounters were excluded from the study. Data were extracted from the central computerized databases of the Medical Corps and Israeli Defense Forces. RESULTS: Sixty-eight physicians had a total of 18,402 encounters that resulted in 23,845 outcomes. There were no associations between demographic and training backgrounds of the physicians and their actual referral rates to consultations and laboratory tests. CONCLUSION: The background data of the primary care physicians does not predict their referral patterns and their role as "gate keepers".     

Various contract settings and their impact on the cost of medical services

OBJECTIVES: This study analyzes the effect of outsourcing healthcare on career soldiers in the Israel Defense Forces (IDF) in different settings, so as to develop a model for predicting per capita medical costs METHODS: Demographic information and data on healthcare utilization and costs were gathered from three computerized billing database systems: The IDF Medical Corps; a civilian hospital; and a healthcare fund, providing services to 3,746; 3,971; and 6,400 career soldiers, respectively. Visits to primary care physicians and specialists, laboratory and imaging exams, number of sick-leave days, and hospitalization days, were totaled for men and women separately for each type of clinic. A uniform cost was assigned to each type of treatment to create an average annual per capita cost for medical services of career soldiers. RESULTS: Significantly more visits were recorded to primary care physician and to specialists, as well as imaging examinations by Leumit Healthcare Services (LHS), than visits and tests in hospitals or in military clinics (p < 0.001). The number of referrals to emergency rooms and sick-leave days were lowest in the LHS as compared to the hospital and military clinics (p < 0.001). The medical cost per capita/year was lowest in LHS as well. CONCLUSIONS: Outsourcing primary care for career soldiers to a civilian healthcare fund represents a major cost effective change, lowest consumption and lower cost of medical care. Co-payment should be integrated into every agreement with the medical corps.     

Army personnel satisfaction in different settings of primary health care clinics

PURPOSE: To analyze patient satisfaction in Israeli Defense Forces primary care clinics (PCCs), and to compare different satisfaction indices that best correlate with general satisfaction index. METHODS: Large-scale patient satisfaction survey throughout all PCCs, classified as active front clinics, training schools clinics, and home front clinics. RESULTS: Participants (5,103) filled out standardized questionnaires. Patients in active front clinics were more satisfied with their PCCs than in the other two settings. Patients showed the highest satisfaction level in the environment questions and the lowest satisfaction level in the accessibility questions. In training school clinics and home front clinics, accessibility questions were most important, whereas in active front clinics, health outcome questions prevailed. CONCLUSIONS: Overall patient satisfaction is the highest in active front clinics, lower in training school clinics, and lowest in home front clinics. Accessibility is the most important factor in patient satisfaction in training school and home front units, and is less important in active front units.     

Malpractice stress syndrome in radiologists and radiotherapists: perceived causes and consequences

PURPOSE: Radiology is among the specialties with an increasing risk of litigation. Regardless of the outcome of legal proceedings, physicians who are sued usually perceive the claim as an assault on their integrity and may suffer psychological or physical effects known as "malpractice stress syndrome". MATERIALS AND METHODS: Two hundred and six radiologists and 108 radiotherapists responded to a questionnaire containing specific items concerning their perception of malpractice stress and their opinions about the causes of clinical errors, as well as an assessment of work satisfaction and general health. RESULTS: One third of physicians had been sued for malpractice. Age was significantly related to the occurrence of malpractice litigation. Radiological errors were purportedly related to occupational discomfort, and the latter variable was significantly associated with work dissatisfaction and a low level of psychological and physical well-being. CONCLUSIONS: Radiologists are well acquainted with medical malpractice and its causes; however, they have limited familiarity with clinical risk management practices and often ignore procedures of informed consent. A targeted educational effort is required to overcome these shortcomings.     

Early pregnancy confirmation--the role of urine pregnancy test in military primary care clinics

Pregnancy detection is a common procedure in primary care and can be challenging in the setting of military primary care clinics. The objective of this study was to determine whether the introduction of urine pregnancy tests to military primary care clinics is associated with earlier pregnancy detection. We conducted a cross-sectional study using data from female soldiers, aged 18 to 20 years. Pregnancy was diagnosed using urine pregnancy tests. Ultrasonographic gestational age at presentation was compared between pregnant soldiers diagnosed in primary care clinics and pregnant soldiers diagnosed in gynecology secondary care clinics. A total of 150 female soldiers performed urine pregnancy tests in 5 different primary care clinics, from which 28 (19%) were pregnant. Mean gestational age at diagnosis was significantly lower among patients diagnosed in primary care clinics as compared with patients diagnosed in gynecology secondary care clinics (41.07 days (SD, 6.72) vs. 48.42 days (SD, 21.94), p < 0.001). In conclusion, the availability of urine pregnancy tests in the setting of military primary care clinics was strongly associated with early pregnancy detection at a time point in which presentation for both antenatal care and abortion services potentially improve maternal and neonatal health.     

Reason for referrals among military primary care physicians.

In order to assess the reasons for high referral rates to secondary medical care services in the Israel Defence Force-Medical Corps, we conducted a study in which 28 physicians in five primary care clinics took part. Seven hundred thirty-seven patients were referred to specialists. The referral reasons were learned from questionnaires filled in for each of these patients. The study shows that factors related to the physicians are important in determining when referral is made: Israeli medical graduates showed less confidence than their peer graduates outside of Israel. A possible explanation is that the Israeli graduates are better prepared for working in a scientific, sophisticated medical environment rather than the ambulatory primary care environment.     

Finally "deliberate by design": milestones in the delivery of health care for U.S. military family members

The development of medical care for U.S. military families and retirees was serendipitous, a fortunate accident. The formal development of military family medical care required the evolution of three factors: the emergence of a standing army, frontiers to guard, and a peace to defend. These factors were first realized in the late 19th Century, and beginning at that point in U.S. history, seven key years highlight major milestones in the history of military family member medical care. At the same time, these years exemplify changing ideas of disease and of health care and how the physical design of clinics and hospitals reflects and impacts these ideas. The Fort Belvoir Community Hospital, which opens in 2011, exemplifies the Nation's best example of green hospital construction, patient and family centered care, and evidence-based design in a Culture of Excellence that demonstrates that military family medical care is finally "deliberate by design."