How do physicians respond to patients’ requests for costly, unindicated services?

Objective  To determine how physicians respond to a request for an expensive, unindicated test. Design  Cross-sectional observational study. Setting  Four sites of a group-model HMO. Participants  Thirty-nine internist volunteers. Intervention  A standardized patient requesting magnetic resonance imaging (MRI) of the head to rule out multiple sclerosis (MS) was inserted unanncounced into physicians’ regular schedules. The patient’s only complaint was fatigue with no neurologic symptoms. Measurements and main results  Physicians and standardized patients completed assessments after each visit. Thirty-five (90%) of 39 physicians “had no idea” that the patient they saw was the standardized patients, and the remaining four participants (10%) were only “somewhat suspicious”. Three (8%) of the physicians agreed to the MRI at the initial visit, and eight (22%) said they might order an MRI in the future. All doctors who refused the MRI told the patient this was based on lack of a medical indication for the test; seven (19%) also cited the test’s expense. Twenty physicians (53%) of 38 agreed to a neurology referral. In response to the standardized patient’s concerns, nine physicians (23%) verbalized that MS is scary, and four (10%) asked the patients about their friend’s experience with MS. A few physicians appeared to dismiss the patient’s concerns, such as by telling the patient they were being “paranoid”. Conclusions  Few physicians agreed to a standardized patient’s request for a medically unindicated MRI, but more than half agreed to refer this patients to a specialist. As physicians practice cost-conscious medicine, they may need to focus on good communication to maintain patient satisfaction. Presented in part at the Robert Wood Johnson Clinical Scholars Program national meeting, November 1995 and the Society of General Internal Medicine national meeting, May 1996. Supported by grants from the Walter and Elise Haas Fund and the Robert Wood Johnson Clinical Scholars Program.     

Physician Compensation from Salary and Quality of Diabetes Care

Objective To examine the association between physician-reported percent of total compensation from salary and quality of diabetes care. Design Cross-sectional analysis. Participants Physicians (n = 1248) and their patients with diabetes mellitus (n = 4200) enrolled in 10 managed care plans. Measurements We examined the associations between physician-reported percent compensation from salary and processes of care including receipt of dilated eye exams and foot exams, advice to take aspirin, influenza immunizations, and assessments of glycemic control, proteinuria, and lipid profile, intermediate outcomes such as adequate control of hemoglobin A1c, lipid levels, and systolic blood pressure levels, and satisfaction with provider communication and perceived difficulty getting needed care. We used hierarchical logistic regression models to adjust for clustering at the health plan and physician levels, as well as for physician and patient covariates. We adjusted for plan as a fixed effect, meaning we estimated variation between physicians using the variance within a particular health plan only, to minimize confounding by other unmeasured health plan variables. Results In unadjusted analyses, patients of physicians who reported higher percent compensation from salary (>90%) were more likely to receive 5 of 7 diabetes process measures and more intensive lipid management and to have an HbA1c<8.0% than patients of physicians who reported lower percent compensation from salary (<10%). However, these associations did not persist after adjustment. Conclusions Our findings suggest that salary, as opposed to fee-for-service compensation, is not independently associated with diabetes processes and intermediate outcomes.     

The quality of medical care provided to vulnerable older patients with chronic pain

OBJECTIVES: To assess the quality of chronic pain care provided to vulnerable older persons. DESIGN: Observational study evaluating 11 process-of-care quality indicators using medical records and interviews with patients or proxies covering care received from July 1998 through July 1999. SETTING: Two senior managed care plans. PARTICIPANTS: A total of 372 older patients at increased risk of functional decline or death identified by interview of a random sample of community dwellers aged 65 and older enrolled in these managed-care plans. MEASUREMENTS: Percentage of quality indicators satisfied for patients with chronic pain. RESULTS: Fewer than 40% of vulnerable patients reported having been screened for pain over a 2-year period. One hundred twenty-three patients (33%) had medical record documentation of a new episode of chronic pain during a 13-month period, including 18 presentations for headache, 66 for back pain, and 68 for joint pain. Two or more history elements relevant to the presenting pain complaint were documented for 39% of patients, and at least one relevant physical examination element was documented for 68% of patients. Treatment was offered to 86% of patients, but follow-up occurred in only 66%. Eleven of 18 patients prescribed opioids reported being offered a bowel regimen, and 10% of patients prescribed noncyclooxygenase-selective nonsteroidal antiinflammatory medications received appropriate attention to potential gastrointestinal toxicity. CONCLUSION: Chronic pain management in older vulnerable patients is inadequate. Improvement is needed in screening, clinical evaluation, follow-up, and attention to potential toxicities of therapy.     

Primary care experiences of medicare beneficiaries, 1998 to 2000

OBJECTIVE: To examine changes in the quality of primary care experienced and reported by Medicare beneficiaries from 1998 to 2000. DESIGN: Longitudinal observational study. SETTING: Thirteen states with large, mature Medicare HMO markets. PARTICIPANTS: Probability sample of noninstitutionalized Medicare beneficiaries aged 65 and older enrolled in traditional Medicare (FFS) or a Medicare HMO. MEASUREMENTS AND MAIN RESULTS: We examined 2-year changes in 9 measures derived from the Primary Care Assessment Survey (PCAS). The measures covered 2 broad areas of primary care performance: quality of physician-patient interactions (5 measures) and structural/organizational features of care (4 measures). For each measure, we computed the change in each beneficiary's score (1998 vs 2000) and standardized effect sizes (ES). Results revealed significant declines in 3 measures of physician-patient interaction quality (communication, interpersonal treatment, and thoroughness of physical exams; P < or = .0001). Physicians' knowledge of patients increased significantly over the 2-year period (P < or = .001). Patient trust did not change (P = .10). With regard to structural/organizational features of care, there were significant declines in financial access (P < or = .001), visit-based continuity (P < .001), and integration of care (P < or = .05), while organizational access increased (P < or = .05). With the exception of financial access, observed changes did not differ by system (FFS, HMO). CONCLUSIONS: Over a 2-year period, the quality of seniors' interactions with their primary physicians declined significantly, as did other hallmarks of primary care such as continuity, integration of care, and financial access. This decline is in sharp contrast to the marked improvements in technical quality that have been measured over this period. In an era marked by substantial national investment in quality monitoring, measures of these elements of care are notably absent from the nation's portfolio of quality indicators.     

Self-disclosure of HIV status,disclosure counseling,and retention in HIV care in Cameroon

Poor retention in care is common among HIV-positive adults in sub-Saharan Africa settings and remains a key barrier to HIV management. We quantify the associations of disclosure of HIV status and referral to disclosure counseling with successful retention in care using data from three Cameroon clinics participating in the Phase 1 International epidemiologic Databases to Evaluate AIDS Central Africa cohort. Of 1646 patients newly initiating antiretroviral therapy between January 2008 and January 2011, 43% were retained in care following treatment initiation. Self-disclosure of HIV status to at least one person prior to treatment initiation was associated with a minimal increase in the likelihood of being retained in care (risk ratio [RR]?=?1.14; 95% confidence interval (CI): 0.94, 1.38). However, referral to disclosure counseling was associated with a moderate increase in retention (RR?=?1.37; 95% CI: 1.21, 1.55) and was not significantly modified by prior disclosure status (p?=?.3). Our results suggest that while self-disclosure may not significantly improve retention among patients receiving care at these Cameroon sites, counseling services may play an important role regardless of prior disclosure status.     

Intention to discontinue care among primary care patients

BACKGROUND: Specific elements of health care process and physician behavior have been shown to influence disenrollment decisions in HMOs, but not in outpatient settings caring for patients with diverse types of insurance coverage. OBJECTIVE: To examine whether physician behavior and process of care affect patients' intention to return to their usual health care practice. DESIGN: Cross-sectional patient survey and medical record review. SETTING: Eleven academically affiliated primary care medicine practices in the Boston area. PATIENTS: 2,782 patients with at least one visit in the preceding year. MEASUREMENT: Unwillingness to return to the usual health care practice. RESULTS: Of the 2,782 patients interviewed, 160 (5.8%) indicated they would not be willing to return. Two variables correlated significantly with unwillingness to return after adjustment for demographics, health status, health care utilization, satisfaction with physician's technical skill, site of care, and clustering of patients by provider: dissatisfaction with visit duration (odds ratio [OR], 3.2; 95% confidence interval [CI], 1.4 to 7.4) and patient reports that the physician did not listen to what the patient had to say (OR, 8.8; 95% CI, 2.5 to 30.7). In subgroup analysis, patients who were prescribed medications at their last visit but who did not receive an explanation of the purpose of the medication were more likely to be unwilling to return (OR, 4.9; 95% CI, 1.8 to 13.3). CONCLUSION: Failure of physicians to acknowledge patient concerns, provide explanations of care, and spend sufficient time with patients may contribute to patients' decisions to discontinue care at their usual site of care.     

信任是和谐医患关系的基础

医患信任的核心意义在于其作为医疗活动过程中的重要基础,是医疗活动顺畅开展下去的保证。当前,医患间信任缺失现象仍然存在,这对于患者疾病的治愈和医学的发展是没有益处的,同时,也不利于和谐医患关系的构建。如何重建医患信任,使医患并肩战斗,战胜病魔,这是急需解决的重要问题。     

HIV disclosure in rural China: predictors and relationship to access to care

This study examined the main reasons and predictors of HIV disclosure and its relationship to access to care among people living with HIV (PLH) in a rural area of China. A sample of 88 PLH from three counties was interviewed in 2009. In our sample, the rates of disclosure were higher within and outside family. Trust (31%), needing help (28%), and close relationships (26%) were the three main reasons of selecting the person to disclose by a PLH. Using a multivariate analysis, level of HIV disclosure to partners and members within the community was only significantly associated with use of antiretroviral treatment (ART) (β = 2.76; 95% Confidence Interval (CI): 0.77, 4.74). After adjusting for demographics, time since HIV diagnosis and ART, we found HIV disclosure (β = 0.07; 95% CI: 0.01, 0.13) was a significant predictor for access to care. In order to improve PLHs' access to health services and care, future intervention programs should consider both the potential benefits and risks associated with HIV disclosure (intentional and unintentional), and assist PLHs to prepare for HIV disclosure and reduce potential negative impacts that come with it.     

Patient-reported and physician-estimated adherence to HAART

OBJECTIVES: To evaluate the rate of discordance between patients and physicians on adherence to highly active antiretroviral therapy (HAART) and identify factors related to discordance in these two assessments. DESIGN: Prospective, multicenter, cohort study (AdICONA) nested within the Italian Cohort Naive Antiretrovirals (ICONA) study. SETTING: Tertiary clinical centers. PARTICIPANTS: The patients filled out a 16-item self-administered questionnaire on adherence to HAART. At the same time, physicians estimated the current HAART adherence of their patient. MAIN OUTCOME MEASURE: Discordance between patient and physician on adherence to antiretroviral therapy. RESULTS: From May 1999 to March 2000, 320 paired patient-physician assessments were obtained. Patients had a mean plasma HIV RNA of 315 copies/ml (64% had undetectable HIV RNA) and a mean CD4+ cell count of 577 cells x 10(6)/L. Nonadherence was reported by 30.9% of patients and estimated by physicians in 45.0% cases. In 111 cases (34.7%), patients and physicians were discordant on adherence to HAART. Kappa statistics was 0.27. Using patient-assessed adherence as reference, sensitivity, specificity, positive predictive value, and negative predictive value of physician-estimated adherence were 64.7%, 66.6%, 81.2%, and 45.8%, respectively. On multivariable analysis, low education level, unemployment, absence of a social worker in the clinical center, and unavailability of afternoon visits were significantly correlated with patient-physician discordance on adherence to antiretrovirals. CONCLUSIONS: Physicians did not correctly estimate patient-reported adherence to HAART in more than one third of patients. Both social variables and factors related to the clinical center were important predictors of discordance between patients and physicians. Interventions to enhance adherence should include strategies addressed to improve patient-physician relationship.     

Mediator and moderator effects on the relationship between HIV-positive status disclosure concerns and health-related quality of life

HIV-related stigma and the effect on quality of life is an on-going public health concern despite decades of education, prevention, and intervention efforts. The main purposes of this study were to examine the mediating role of four coping styles and the moderating role of gender on the relationship between HIV-positive status disclosure concerns and eight health-related quality of life outcomes. Data were collected from 346 women and men living with HIV. Results indicated that two coping styles – acquiring social support and positive reframing – mediated the negative relationship between disclosure concerns and health-related quality of life outcomes. There was no support for a moderated mediation. Interventions aimed at helping people living with HIV should focus on identifying and acquiring coping styles that transform perceptions of HIV-related stigma to support disclosure and improve health-related quality of life.     

Physician board certification and the care and outcomes of elderly patients with acute myocardial infarction

BACKGROUND: Patients and purchasers prefer board-certified physicians, but whether these physicians provide better quality of care and outcomes for hospitalized patients is unclear. OBJECTIVE: We evaluated whether care by board-certified physicians after acute myocardial infarction (AMI) was associated with higher use of clinical guideline recommended therapies and lower 30-day mortality. SUBJECTS AND METHODS: We examined 101,251 Medicare patients hospitalized for AMI in the United States and compared use of aspirin, beta-blockers, and 30-day mortality according to the attending physicians' board certification in family practice, internal medicine, or cardiology. RESULTS: Board-certified family practitioners had slightly higher use of aspirin (admission: 51.1% vs 46.0%; discharge: 72.2% vs 63.9%) and beta-blockers (admission: 44.1% vs 37.1%; discharge: 46.2% vs 38.7%) than nonboard-certified family practitioners. There was a similar pattern in board-certified Internists for aspirin (admission: 53.7% vs 49.6%; discharge: 78.2% vs 68.8%) and beta-blockers (admission: 48.9% vs 44.1%; discharge: 51.2% vs 47.1). Board-certified cardiologists had higher use of aspirin compared with cardiologists certified in internal medicine only or without any board certification (admission: 61.3% vs 53.1% vs 52.1%; discharge: 82.2% vs 71.8% vs 71.5%) and beta-blockers (admission: 52.9% vs 49.6% vs 41.5%; discharge: 54.7% vs 50.6% vs 42.5%). In multivariate regression analyses, board certification was not associated with differences in 30-day mortality. CONCLUSIONS: Treatment by a board-certified physician was associated with modestly higher quality of care for AMI, but not differences in mortality. Regardless of board certification, all physicians had opportunities to improve quality of care for AMI.     

Statewide Evaluation of Measuring Physician Delivery of Self-Management Support in Chronic Disease Care

BACKGROUND  Self-management support is an important component of improving chronic care delivery. OBJECTIVE  To validate a new measure of self-management support and to characterize performance, including comparisons across chronic conditions. DESIGN, SETTING, PARTICIPANTS  We incorporated a new question module for self-management support within an existing annual statewide patient survey process in 2007. MEASUREMENTS  The survey identified 80,597 patients with a chronic illness on whom the new measure could be evaluated and compared with patients’ experiences on four existing measures (quality of clinical interactions, coordination of care, organizational access, and office staff). We calculated Spearman correlation coefficients for self-management support scores for individual chronic conditions within each medical group. We fit multivariable logistic regression models to identify predictors of more favorable performance on self-management support. RESULTS  Composite scores of patient care experiences, including quality of clinical interactions (89.2), coordination of care (77.6), organizational access (76.3), and office staff (85.8) were higher than for the self-management support composite score (69.9). Self-management support scores were highest for patients with cancer (73.0) and lowest for patients with hypertension (67.5). The minimum sample size required for medical groups to provide a reliable estimate of self-management support was 199. There was no consistent correlation between self-management support scores for individual chronic conditions within medical groups. Increased involvement of additional members of the healthcare team was associated with higher self-management support scores across all chronic conditions. CONCLUSION  Measurement of self-management support is feasible and can identify gaps in care not currently included in standard measures of patient care experiences.     

Healthcare utilization and costs in managed care patients with Alzheimer's disease during the last few years of life

OBJECTIVES: To learn whether managed care patients with Alzheimer's disease (AD) are more or less costly to care for than patients with other forms of dementia or patients without dementia during the last few years of life. DESIGN: Case control study. SETTING: A health maintenance organization base population. PARTICIPANTS: Three groups of subjects (mean age 85) who were deceased members of a dementia registry obtained from a health maintenance organization base population: 263 subjects with clinically diagnosed probable AD, 133 subjects with other forms of dementia, and 100 cognitively intact controls. MEASUREMENTS: Utilization records were examined for the 3 years preceding death. RESULTS: In all subcategories and in aggregate, utilization and costs of care were either similar or lower for patients with AD than for the other groups, even after controlling for age, gender, and comorbidity. CONCLUSIONS: Persons with AD do not incur higher costs than persons with other types of dementia or age-matched persons without dementia in a mature health maintenance organization during the last few years of life, when utilization is likely to be highest.     

The development of a palliative care program for managed care patients: a case example

Palliative care is emerging as an important new field. Although programs are developing in hospital environments, little is known about development of programs in outpatient practices or those serving large managed care populations. This article provides a framework for the development of a comprehensive palliative care program in a large multispecialty group practice that serves managed care patients. The article addresses guiding principles, the need for obtaining baseline data, how the clinical consultation service was established, development of outcomes measures, and information on current program status. Five themes emerged as key to successful program development, most importantly the close collaboration between administrative and clinical staff in all aspects of program development.     

Patient Experiences with Coordination of Care: The Benefit of Continuity and Primary Care Physician as Referral Source

BACKGROUND  Coordination across a patient’s health needs and providers is important to improving the quality of care. OBJECTIVES  (1) Describe the extent to which adults report that their care is coordinated between their primary care physician (PCP) and specialists and (2) determine whether visit continuity with one’s PCP and the PCP as the referral source for specialist visits are associated with higher coordination ratings. DESIGN  Cross-sectional study of the 2007 Health Tracking Household Survey. PARTICIPANTS  A total of 3,436 adults with a PCP and one or more visits to a specialist in the past 12 months. MEASUREMENTS  Coordination measures were patient perceptions of (1) how informed and up to date the PCP was about specialist care received, (2) whether the PCP talked with the patient about what happened at the recent specialist visit and (3) how well different doctors caring for a patient’s chronic condition work together to manage that care. RESULTS  Less than half of respondents (46%) reported that their PCP always seemed informed about specialist care received. Visit continuity with the PCP was associated with better coordination of specialist care. For example, 62% of patients who usually see the same PCP reported that their PCP discussed with them what happened at their recent specialist visit vs. 48% of those who do not usually see the same PCP (adjusted percentages, p < 0.0001). When a patient’s recent specialist visit was based on PCP referral (vs. self-referral or some other source), 50% reported that the PCP was informed and up to date about specialist care received (vs. 35%, p < 0.0001), and 66% reported that their PCP discussed with them what happened at their recent specialist visit (vs. 47%, p < 0.0001). CONCLUSIONS  Facilitating visit continuity between the patient and PCP, and encouraging the use of the PCP as the referral source would likely enhance care coordination.     

Hospital Readmissions: Physician Awareness and Communication Practices

Background  Patients requiring early hospital readmission may be readmitted to different physicians, potentially without the knowledge of the prior caregivers. This lost opportunity to share information about readmitted patients may be detrimental to quality of care and resident education. Objective  To measure physician awareness of and communication about readmissions. Design  Cross-sectional study. Setting  Two academic medical centers. Participants  A total of 432 patients discharged from the general medicine services and readmitted within 14 days. Measurements  We identified patients discharged from the general medicine services and readmitted within 14 days, excluding patients readmitted to the same physician(s) and planned readmissions. We surveyed discharging and readmitting physicians 48 h after the time of readmission. Results  Discharging physician teams were aware of 48.5% (95% CI 41.5%-55.5%) of patient readmissions. Communication between teams occurred on 43.7% (95% CI 37.1%-50.3%). Higher medical complexity was associated with an increased likelihood of physician communication (adjusted OR 1.12, 95% CI 1.06–1.19). When communication occurred, readmitting physicians received information about the discharging team’s overall assessment (61.9%, 95% CI 51.9%-71.9%), psychosocial issues (52.6%, 95% CI 42.4%-62.8%), pending tests (34.0%, 95% CI 24.2%-43.8%), and discharge medications (30.9%, 95% CI 21.5%-40.3%). When communication did not occur, most physicians (60.8%, 95% CI 56.7%-64.9%) responded it would have been desirable to communicate. Conclusions  Physicians are frequently unaware of patient readmissions and often do not communicate when readmissions occur. This communication is often desired and frequently results in the exchange of important patient information. Further work is needed to design systems to address this potential discontinuity of care.     

Gender differences in disclosure concerns and HIV-related quality of life

HIV-related disclosure concerns are associated with higher rates of concealment and poorer well-being, including poorer health related HIV quality of life (HIV-QOL). Little research, however, has examined whether gender differences exist in the links between HIV disclosure concerns and HIV-QOL. We expected that disclosure concerns and gender would be associated with HIV-QOL, such that the relationship between disclosure concerns and poorer HIV-QOL to be stronger in women living with HIV (WLWH) than in men living with HIV (MLWH). One hundred and forty MLWH (n?=?102) and WLWH (n?=?38) completed an online questionnaire consisting of measures regarding their demographics, disclosure concerns (HIV-stigma scale), and HIV-QOL (HIV-AIDS-Targeted Quality of Life Instrument). Results suggested that more disclosure concerns were associated with poorer HIV-QOL, but in general, men and women did not differ in their levels of HIV-QOL. As expected, interactions emerged between gender and disclosure concerns such that disclosure concerns were associated with increased health worries and poorer sexual functioning for WLWH but not for MLWH. Interventions should acknowledge the differing needs and experiences of WLWH in order to improve HIV-QOL and increase longevity.     

Physician Reminders to Promote Surveillance Colonoscopy for Colorectal Adenomas

Background  Most colorectal cancers develop from adenomatous polyps. National guidelines recommend surveillance colonoscopy within 5 years after such polyps are removed. Objective  To determine whether surveillance colonoscopy can be increased among overdue patients by reminders to their primary physicians. Design  Randomized, controlled trial of patient-specific reminders mailed to 141 physicians in 2 Massachusetts primary care networks during April, 2006. Patients  Seven hundred seventeen patients who had colorectal adenomas removed during 1995 through 2000 and no follow-up colonoscopy identified via automated review of electronic records through March, 2006. Measurements and Main Results  The use of colonoscopy and detection of new adenomas or cancer were assessed at 6 months by a blinded medical record review in all patients. Among 358 patients whose physicians received reminders, 33 (9.2%) patients underwent colonoscopy within 6 months, compared with 16 (4.5%) of 359 patients whose physicians did not receive reminders (P = 0.009). In prespecified subgroups, this effect did not differ statistically between 2 primary care networks, elderly and nonelderly patients, or women and men (all P > 0.60 by Breslow–Day test). New adenomas or cancer were detected in 14 (3.9%) intervention patients and 6 (1.7%) control patients (P = 0.06), representing 42.4% and 37.5% of patients who underwent colonoscopy in each group, respectively. Despite using advanced electronic health records to identify eligible patients, 22.5% of enrolled patients had a prior follow-up colonoscopy ascertained only by visual record review, and physicians reported 27.9% of intervention patients were no longer active in their practice. Conclusions  Among patients with prior colorectal adenomas, physician reminders increased the use of surveillance colonoscopy, but better systems are needed to identify eligible patients (ClinicalTrials.gov ID number NCT00397969). The study was presented at the Annual Meeting of the Society of General Internal Medicine in Toronto, Ontario on April 26, 2007.     

人文关怀也是一种治疗

随着医学模式的转变及患者需求的增加,人文关怀逐渐在治疗中显现出其与医学技术同样重要的作用。通过对临床工作的观察,阐释了医学人文关怀在安抚患者心理、加深医患互信、弥补医学技术不足、加强护理细节教育以及促进患者健康恢复等方面的重要作用。