Use of reminders for preventive procedures in family medicine.

OBJECTIVE: To compare the effectiveness of three computerized reminder systems in the delivery of five preventive procedures in family practice. DESIGN: Prospective, randomized, controlled study. SETTING: Ottawa Civic Hospital Family Medicine Centre. PARTICIPANTS: Of 8502 patients 15 years of age or more who were not in a hospital or institution 5883 were randomly assigned, by family, to a control group, a physician reminder group (passive) or a telephone or letter reminder group (active). The remaining 2619 patients were not included in the randomized portion of the study but were monitored. INTERVENTION: During 1 year the patients in the active reminder groups received a telephone call or letter reminding them of any overdue preventive procedures; for those in the passive reminder group the physician was reminded at an office visit to provide any overdue service. OUTCOME MEASURE: Rates of completion of the preventive procedures required. MAIN RESULTS: All three reminder systems significantly improved the delivery of preventive services (p less than 0.001). The procedure completion rates were 42.0% in the letter reminder group, 42.0% in the telephone reminder group, 33.7% in the physician reminder group and 14.1% in the randomized control group. The use of a letter was more cost-effective than the telephone system, but the physician reminder system was the most cost-effective. CONCLUSION: Computerized reminder systems do improve the delivery of preventive services in family practice.     

Computer assisted screening: effect on the patient and his consultation

The initial impact of computer assisted preventive screening in general practice consultations has been monitored. The technology has not been found stressful by patients, and the power of the consultation to alleviate low arousal has been increased by computer use. No appreciable increase in the durations of consultation was detected, despite an average computer initiated input of two minutes eight seconds. The computer has successfully prompted preventive screening and health education with a sixfold increase in the number of potentially relevant procedures being mentioned. The actual information presented by the computer has been shown to be crucial, with the terminal's mere presence an ineffective reminder. The computer terminal was used in 65% of the consultations for which it was available, which, if sustained, represents an effective screening programme for attending patients.     

Influenza vaccination in the elderly: 2. The economics of sending reminder letters

Reminder letters and follow-up telephone calls were used to increase influenza vaccination acceptance by 273 well elderly registered at an urban community health centre. The net effect of the reminder letters was to increase overall coverage to 43%, from 17% in the previous year. Follow-up telephone calls to patients who had not responded to the letters increased coverage to only 55%. Calculation of costs per additional vaccination given revealed that the use of reminder letters alone was much more cost-effective than follow-up telephone calls in increasing coverage. However, with the current fee-for-service reimbursement by medical care insurance in Ontario, neither means of improving vaccination coverage would result in net practice earnings. The implications for an effective and efficient annual influenza program in Canada are discussed.     

Comparison of three methods of recalling patients for influenza vaccination.

Despite recommendations supporting annual influenza vaccination for people aged 65 years or older, vaccination rates remain low. Several studies have evaluated the effect of sending mailed reminders, but few have compared alternative ways of reminding patients to receive the vaccine. In a randomized trial of 939 patients aged 65 years or older in four family practices carried out between Oct. 23 and Dec. 31, 1984, we compared three ways of reminding elderly patients to receive the vaccine: personal reminder by the physician, telephone reminder by the nurse and reminder by letter. The vaccination rates for the three groups were 22.9%, 37% and 35.1% respectively. No reminder was issued to a control group, and the rate was 9.8%. Some patients could not be reached by telephone, and some did not see the physician during the specified time. Among the patients whom the nurse actually contacted, the vaccination rate was 43.5%; the rate for patients whom the doctor actually saw was 45.1%. Overall, a telephone reminder by the nurse was the most effective method, and at an hourly salary of $16 or less this method would also be the most cost-effective. The reminders used in this study were automatically generated from a computerized medical record system. The study shows how a computerized system can be used to identify patients for whom preventive procedures are due.     

Prompting Clinicians about Preventive Care Measures: A Systematic Review of Randomized Controlled Trials

Preventive care measures remain underutilized despite recommendations to increase their use. The objective of this review was to examine the characteristics, types, and effects of paper- and computer-based interventions for preventive care measures. The study provides an update to a previous systematic review. We included randomized controlled trials that implemented a physician reminder and measured the effects on the frequency of providing preventive care. Of the 1,535 articles identified, 28 met inclusion criteria and were combined with the 33 studies from the previous review. The studies involved 264 preventive care interventions, 4,638 clinicians and 144,605 patients. Implementation strategies included combined paper-based with computer generated reminders in 34 studies (56%), paper-based reminders in 19 studies (31%), and fully computerized reminders in 8 studies (13%). The average increase for the three strategies in delivering preventive care measures ranged between 12% and 14%. Cardiac care and smoking cessation reminders were most effective. Computer-generated prompts were the most commonly implemented reminders. Clinician reminders are a successful approach for increasing the rates of delivering preventive care; however, their effectiveness remains modest. Despite increased implementation of electronic health records, randomized controlled trials evaluating computerized reminder systems are infrequent.     

Preventive care in daily practice

Advances in medical science have led to effective preventive steps that can be used by all physicians; however, most current preventive evaluations and applications are given in primary care settings. Hence, integrating preventive care into practice has become an important challenge for all primary care physicians. This article reviews the delivery of clinical prevention including implementation, barriers, and management. It is clear that preventive care leads to healthier people and that should be the goal of all medicine.     

Challenges in family medicine

Family medicine has matured over the last 30 years. It has become a discipline but acceptance as a specialty is still not universal. It needs to pay attention to developing intellectual vigour and capacity building to meet peoples' needs. Opportunities to do so abound, namely in preventive care, geriatric care and care of chronic diseases. Future challenges lie in capacity building in practice, teaching and research. The setting up of a vocational register for trained family physicians and charging an adequate fee are important mechanisms to improve its image.     

Computerization of family practice.

The primary focus of computer systems for family practice is on patient billing. Primary care physicians should be aware of the many other benefits that can and should be considered when planning a system for their practice. This article describes the type and extent of information that can be stored in a family practice data base and explores some of the applications in areas of practice and patient management, prevention and research.     

Measuring physicians' performances by using simulated patients

The authors in this paper discuss a new approach to the assessment of physicians' performances in practice using undetected standardized (simulated) patients. Case-specific performance criteria were established for seven standardized patients by eight family physicians and two specialists. The patients were then introduced into the practices of the family physicians and of a second cohort of seven family physicians. No differences were found between the criteria-setting and the noncriteria-setting physicians; but large differences were found among the criteria, the physicians' performances as indicated by the patient, and the data recorded by the physicians on the patient chart. Depending on the method used to score the performance and the recorded data, about 30 to 45 percent of the procedures were not performed, and 50 to 70 percent of the criteria were not recorded. The implications of the study for assessment of physician performance are discussed.     

Utilization of sigmoidoscopy by family physicians in Canada.

OBJECTIVE: To determine the extent to which sigmoidoscopy is used as an investigative tool by family physicians in Canada. DESIGN: Retrospective study of data from provincial and territorial health agencies for the fiscal year 1989. SETTING: Canada. PARTICIPANTS: All family physicians. MAIN OUTCOME MEASURES: Number of physicians in each province and territory who performed sigmoidoscopy (flexible and rigid), type of physician (generalist or specialist), number of procedures performed, fee schedule and number of physicians billing medicare in each province and territory. RESULTS: During the study period 3849 (15.1%) of all family physicians performed rigid sigmoidoscopy; the proportion varied from 3.4% (in Quebec) to 40.0% (in the Northwest Territories). A total of 43,914 rigid sigmoidoscopies were performed by family physicians, representing 23% of all such procedures. Flexible sigmoidoscopy was performed by 381 (1.5%) of all family physicians; the proportion varied from 0.4% (in Quebec) to 6.8% (in Prince Edward Island). A total of 5361 flexible sigmoidoscopies were performed, representing 6.0% of all such procedures. CONCLUSION: The proportion of Canadian family physicians who are using sigmoidoscopy, rigid or flexible, as a diagnostic tool is low.     

Provision of preventive care to unannounced standardized patients

OBJECTIVE: To examine the relation between physician, training and practice characteristics and the provision of preventive care as described in the guidelines of the Canadian Task Force on the Periodic Health Examination. DESIGN: Cross-sectional study. SETTING: Family practices open to new patients within 1 hour's drive of Hamilton, Ont. PARTICIPANTS: A total of 125 family physicians were randomly selected from respondents to an earlier preventive care survey. Of the 125, 44 (35.2%) declined to participate, and an additional 19 (15.2%) initially consented but later withdrew when they closed their practices to new patients. Sixty-two physicians thus participated in the study. INTERVENTION: Unannounced standardized patients posing as new patients to the practice visited study physicians' practices between September 1994 and August 1995, portraying 4 scenarios: 48-year-old man, 70-year-old man, 28-year-old woman and 52-year-old woman. OUTCOME MEASURES: Proportion of preventive care manoeuvres carrying grade A, B, C, D and E recommendations from the Canadian Task Force on the Periodic Health Examination that were performed, offered or advised. A standard score was computed based on the performance of grade A and B manoeuvres (good or fair evidence for inclusion in the periodic health examination) and the non-performance of grade D and E manoeuvres (fair or good evidence for exclusion from the periodic health examination). RESULTS: Study physicians performed or offered 65.6% of applicable grade A manoeuvres, 31.0% of grade B manoeuvres, 22.4% of grade C manoeuvres, 21.8% of grade D manoeuvres and 4.9% of grade E manoeuvres. The provision of evidence-based preventive care was associated with solo (v. group) practice and capitation or salary (v. fee-for-service) payment method. Preventive care performance was unrelated to physician's sex, certification in family medicine or problem-based (v. traditional) medical school curriculum. CONCLUSIONS: Preventive care guidelines of the Canadian Task Force on the Periodic Health Examination have been incompletely integrated into clinical practice. Research is needed to identify and reduce barriers to the provision of preventive care and to develop and apply effective processes for the creation, dissemination and implementation of clinical practice guidelines.     

美国新毕业家庭医生寻找产科相关工作的体验

背景　足够的产科家庭医生对于确保患者获取必需的产科服务至关重要。然而,既往研究表明执业范围包含产科的家庭医生数量正在逐年减少,如今从事新生儿接生工作的家庭医生不到10%。目的　旨在探究希望将产科纳入其执业范围的新毕业家庭医生如何发现和选择工作,并进一步了解当前就业形势对家庭医生的执业范围,特别是产科、新生儿接生方面的影响。方法　于2017年进行问卷调查和定性访谈的混合方法研究。对美国家庭医生进行电子问卷调查并在目的性子抽样后对这些医生进行深度半结构化电话访谈。问卷调查总结了家庭医生未从事产科工作的原因,为进一步明确选择从事产科工作的家庭医生的具体情况,采用基于群体的沉浸式方法来转译定性访谈的结果。本研究向2 098例毕业于2014-2016年并希望从事新生儿接生工作的美国家庭医学专业实习医生发送调查问卷,回复1 016份,回复率48.43%,其中56例接受了电话访谈。结果　问卷调查结果显示,未能找到工作范围包含产科的工作是希望从事产科工作的家庭医学毕业生未从事该工作的主要原因。定性访谈结果显示,家庭医生通常通过人脉关系或人才招聘的途径找到产科相关工作,并根据地理位置偏好、家庭义务及生活方式要求等个人考虑因素做出选择。同时,求职过程和择业决策也受到工作结构、执业特点及缺乏产科相工作经验等因素的限制。结论　虽然个人意向决定大部分医学生的工作选择,但其选择仍受到多种不可控因素限制,特别是家庭医学工作提供产科相关工作的能力。美国毕业医学生从医院实习生到执业医师的转变同时影响着毕业生的求职选择和医疗机构患者寻求医疗服务的质量。因此,了解就业情况对家庭医生就业范围的影响方式,有助于进一步明确如何协助家庭医生在其希望从事的范围内工作并对其进行相应协助,从而确保每一个家庭可以获得更好的医疗服务。     

Quality of care in family practice: does residency training make a difference?

As the proportion of physicians who enter residency training in family practice steadily increases, so does the need to evaluate the impact of their training and postgraduate education on the quality of care in their practices. We audited the practices of 120 randomly selected family physicians in Ontario, who were separated into four groups: nonmembers of the College of Family Physicians of Canada (CFPC), members of the CFPC with no certification in family medicine, certificated members without residency training in family medicine and certificated members with residency training in family medicine. The practices were assessed according to predetermined criteria for charting, procedures in periodic health examination, quality of medical care and use of indicator drugs. Generally the scores were significantly higher for CFPC members with residency training in family medicine than for those in the other groups, nonmembers having the lowest scores. Patient questionnaires indicated no difference in satisfaction with specific aspects of care between the four groups. Self-selection into residency training and CFPC membership may account for some of the results; nevertheless, the findings support the contention that residency training in family medicine should be mandatory for family physicians.     

Mini Medical Record Application: Annual Register for Flu Shot Vaccinations

This application is an Intranet-based system. A database has been established utilizing patient information on the basis of age, medical diagnosis and employment history. If a health care provider or support staff states that a patient is over 65 years of age or has been diagnosed with a chronic disease and this limits the patient’s ability to fight off infection, the need for preventive care is activated. In this situation the preventive care is the administration of an annual flu shot. For anyone over 65 years of age or with a chronic illness, a bulk mail of reminder cards with the dates of availability of injection is generated and mailed. All health care workers are notified at work of vaccination sites that they can use. In addition, should a patient have an appointment with a provider and a preventive flu injection is indicated, a reminder appears on the registration form. This reminder indicates a flu shot is needed as well as other preventive intervention.     

Blended payment methods in physician organizations under managed care.

CONTEXT: Independent practice associations (IPAs) are developing new methods of physician reimbursement to balance the objectives of encouraging individual productivity and clinical cooperation. The economic literature on payment incentives, derived from nonhealth industries, predicts that methods blending elements of fee-for-service and capitation will outperform exclusive reliance on either form of payment. OBJECTIVE: To identify emerging payment methods within IPA physician groups that contract with managed care organizations. DESIGN AND SETTING: Case studies of 7 large IPAs in the San Francisco, Calif, metropolitan region that served 826000 health maintenance organization (HMO) patients during the summer and fall of 1998. MAIN OUTCOME MEASURE: Payment methods of IPAs for primary care physicians, specialists, and physicians grouped by specialty department within the overall IPA structure. RESULTS: All the IPAs contracted with multiple HMOs for the full range of primary and specialty care physicians' services but paid member physicians using methods that blended elements of fee-for-service and subcapitation. For primary care, most IPAs used monthly capitation adjusted for patient age, sex, and selected diagnoses, supplemented with fee-for-service payment for a wide range of visits and procedures, including patient visits in subacute, skilled nursing facility, emergency department, or home settings; for preventive care services; for office procedures requiring expensive supplies; and, most importantly, for borderline primary care procedures that either could be performed directly or referred to specialty care. All the IPAs paid specialty departments on a capitated basis and delegated to the departments responsibility for allocating the budget among individuals. Allocation mechanisms for individual specialists included adjusted fee-for-service, referral-based capitation, and blends of both. CONCLUSION: Our results and case studies indicate that IPAs are developing payment methods that blend elements of fee-for-service and capitation in innovative ways for primary care and specialty physicians.     

中国家庭医生签约服务中激励机制对医生行为影响的理论研究

背景　推进家庭医生签约服务是转变中国基层医疗卫生服务模式的重要举措,是深化医药卫生体制改革的重要任务,也是实现“健康中国2030”战略的基石。合理的激励机制是家庭医生发挥自身能动性的重要保证因素,但是目前家庭医生的激励机制,尤其是医疗保险补偿方式的转变,对其行为的影响尚缺乏相关理论分析。目的　以医生代理理论为支撑,构建符合中国国情的家庭医生行为理论分析框架和模型。方法　以医生代理理论为基础,构建家庭医生在不同医保支付方式下,尤其是按项目付费和按人头付费并存的情况下医生行为分析模型。结果　按项目付费时,道德风险不可避免,医生没有任何动机来抑制患者因道德风险而产生的额外需求;按人头付费后家庭医生的总利润会提高,但是从患者健康中得到的效用值会下降;推行总额预付的前提是设计合理的医疗服务数量和质量,否则家庭医生就会有选择患者的动机。中国家庭医生的收入主要来源于按项目付费方式的医疗收入和按人头签约得到的服务费,提高签约服务费占收入比例可以提高家庭医生的服务质量,但是由于收入中占较大比例的是按项目付费获得的收入,收入的增加不一定能够对患者的质量提供正向影响。结论　中国的基层医疗卫生机构家庭医生的支付方式应该逐步转变为按人头付费,目前可以通过逐步提高家庭医生签约服务费占收入比例的方式,激励家庭医生提供更高质量的医疗服务。     

Factors associated with the decision of family physicians to provide intrapartum care.

OBJECTIVE: To investigate which characteristics and beliefs of family physicians determine their decision to provide intrapartum care. DESIGN: Confidential survey questionnaire mailed in spring 1993. SETTING: Alberta and Ontario. SUBJECTS: Random selection of 207 physicians who had graduated from medical school between 1953 and 1990 and were thought to be in family or general practice. Of 178 eligible physicians, usable replies were received from 104 (58.4%). OUTCOME MEASURES: Beliefs (measured on a 7-point Likert scale) about the relevance of 16 primary factors to the type of obstetric care provided; demographic, training and practice characteristics. RESULTS: The respondents who provided intrapartum care differed from those who did not in their beliefs about the availability of a local hospital suitable for intrapartum care (p < 0.001), their practice partners' views on the role of family physicians in providing obstetric care (p < 0.002), their own concept of the role of family physicians in providing obstetric care (p < 0.001) and women's views on the type of obstetric care they want (p < 0.002). They also differed, although less significantly, in their beliefs about the adequacy of their obstetric training before entering family practice (p < 0.04), the expected effects of providing obstetric care on their free time (p < 0.006), their fear of malpractice litigation (p < 0.028) and their perceived competence in performing practical obstetric procedures (p < 0.05). Logistic regression analysis revealed that certain secondary factors were particularly relevant to the respondents' provision of intrapartum care at present. These included the physician's perceived competence at managing postpartum maternal hemorrhage (odds ratio [OR] 48.90, 90% confidence interval [CI] 4.70 to 509), the belief that medical insurance premiums should not be affected by the type of obstetric care provided (OR 3.55, 90% CI 1.67 to 7.57]) and the number of practice partners who provided intrapartum care (OR 10.08, 90% CI 2.31 to 44.10). CONCLUSION: Several factors appear to influence family physicians in their decision to provide intrapartum care. This information will help to focus efforts to provide appropriate obstetric training for family practice residents and to retain involvement of family physicians in intrapartum care.     

Correlates of certification in family medicine in the billing patterns of Ontario general practitioners.

There is conflicting evidence as to whether physicians who are certified in family medicine practise differently from their noncertified colleagues and what those differences are. We examined the extent to which certification in family medicine is associated with differences in the practice patterns of primary care physicians as reflected in their billing patterns. Billing data for 1986 were obtained from the Ontario Health Insurance Plan for 269 certified physicians and 375 noncertified physicians who had graduated from Ontario medical schools between 1972 and 1983 and who practised as general practitioners or family physicians in Ontario. As a group, certificants provided fewer services per patient and billed less per patient seen per month. They were more likely than noncertificants to include counselling, psychotherapy, prenatal and obstetric care, nonemergency hospital visits, surgical services and visits to chronic care facilities in their service mix and to bill in more service categories. Certificants billed more for prenatal and obstetric care, intermediate assessments, chronic care and nonemergency hospital visits and less for psychotherapy and after-hours services than noncertificants. Many of the differences detected suggest a practice style consistent with the objectives for training and certification in family medicine. However, whether the differences observed in our study and in previous studies are related more to self-selection of physicians for certification or to the types of educational experiences cannot be directly assessed.     

Preventive practice among primary care physicians in British Columbia: relation to recommendations of the Canadian Task Force on the Periodic Health Examination.

OBJECTIVES: To compare the current practice of preventive medicine in British Columbia with the recommendations of the Canadian Task Force on the Periodic Health Examination. Four common, preventable forms of cancer (cervical, breast, lung and colorectal) were used as sentinel conditions. DESIGN: Random sample mailed survey. SETTING: Private primary care practices in British Columbia. PARTICIPANTS: A sample of 300 primary care physicians in 1991; of 285 eligible physicians 185 (65%) responded. OUTCOME MEASURE: Compliance with preventive practices recommended by the task force. RESULTS: Preventive practice complied with the task force's recommendations for breast examinations, mammography, cervical smears and initial counselling against smoking; over 90% of the physicians performed these manoeuvres in all or most cases. However, less than half performed two recommended manoeuvres for all or most patients who smoke: advice to follow a diet high in beta-carotene (reported by 10%) and scheduling of follow-up visits to reinforce antismoking counselling (by 46%). Most of the physicians stated that they perform preventive manoeuvres in the context of an annual general physical examination rather than integrating them into routine patient care. CONCLUSIONS: The task force's carefully constructed recommendations are incompletely followed. Overall, there appears to be a high level of compliance with traditional and recommended manoeuvres but also widespread persistence in performing traditional manoeuvres no longer recommended and failure to adopt new recommendations.