The relationship between primary care physicians' adherence to guidelines for the treatment of diabetes and patient satisfaction: findings from a pilot study

BACKGROUND: Adherence to clinical guidelines improves health care outcomes, reduces expenditure and prevents the complication of unnecessary interventions. It is uncertain what effect the adherence to guidelines for treating diabetes has on patient satisfaction. Some authors have reported that the use of guidelines does not affect patient satisfaction with care, and have concluded that satisfaction is related to a physician's interpersonal skills, rather than to the quality of care. Others have reported that structured intervention programmes improve patient satisfaction with care. OBJECTIVE: The purpose of our study was to explore the association between adherence to clinical guidelines and satisfaction with care among diabetics. METHODS: The study population included 135 randomly sampled diabetes patients listed with 12 primary care physicians at two health plans in Israel, which together insure >80% of the population. Telephone interviews were conducted with the patients between August and November 2000, using structured questionnaires. Patients were asked to report on the extent to which their primary care physician treated them as indicated by the clinical guidelines of these health plans. They were also asked to rate their satisfaction with their primary care physician and the treatment of their disease. Bi-variate analysis was conducted using the chi-square statistical significance test. Multivariate analysis was conducted using logistic regression models. RESULTS: Adherence to guidelines for diabetes was associated with patient satisfaction with care, independently of the patient's ethnicity (first language), age, gender, education, medication (insulin versus other) and health plan affiliation. CONCLUSION: Patients who report being treated as recommended in practice guidelines were more likely to be satisfied with their care. This finding may encourage primary care physicians to adhere to clinical practice guidelines.     

The 'difficult patient' as perceived by family physicians

OBJECTIVES: The aim of this study is to understand in depth the experience of the family physician faced with the patient that he perceives as 'difficult'. This was done by means of the 'long interview' as a method of qualitative research. METHOD: We interviewed 15 randomly selected Board-certified family physicians, with five or more years experience as specialists, employed in the northern district of the 'Clalit Health Services', the major sick fund in Israel. RESULTS: The participants stated that the 'difficult' patients are not those with difficult medical problems but rather those who are violent, demanding, aggressive, rude and who seek secondary gain. Patients with multiple non-specific complaints and those with psychosomatic problems are also difficult for the family physician. Appropriate use of patient-doctor communication skills and an effort to improve relations with the patient through empathy, tolerance and non-judgmental listening were suggested by the physicians as ways of making the difficult encounter easier. CONCLUSIONS: Family physicians acknowledge their responsibility for the 'difficult' patient, and seek innovative and creative ways to cope with the difficult medical encounter. The more experienced the doctor is, the less he perceives patients as 'difficult', as he learns to accept greater diversity of behaviours in his patients.     

Differences in Cardiovascular Disease Risk Factor Management in Primary Care by Sex of Physician and Patient

PURPOSE The purpose of this study was to evaluate differences in the management of cardiovascular disease (CVD) risk factors based upon the sex of the patient and physician and their interaction in primary care practice.METHODS We evaluated CVD risk factor management in 4,195 patients cared for by 39 male and 16 female primary care physicians in 30 practices in southeastern New England.RESULTS Many of the sex-based differences in CVD risk factor management on crude analysis are lost once adjusted for confounding factors found at the level of the patient, physician, and practice. In multilevel adjusted analyses, styles of CVD risk factor management differed by the sex of the physician, with more female physicians documenting diet and weight loss counseling for hypertension (odds ratio [OR] = 2.22; 95% confidence interval [CI], 1.12–4.40) and obesity (OR = 2.14; 95% CI, 1.30–3.51) and more physical activity counseling for obesity (OR = 2.03; 95% CI, 1.30–3.18) and diabetes (OR = 6.55; 95% CI, 2.01–21.33). Diabetes management differed by the sex of the patient, with fewer women receiving glucose-lowering medications (OR = 0.49; 95% CI, 0.25–0.94), angiotensin-converting enzyme inhibitor therapy (OR = 0.39; 95% CI, 0.22–0.72), and aspirin prophylaxis (OR = 0.30; 95% CI, 0.15–0.58).CONCLUSION Quality of care as measured by patients meeting CVD risk factors treatment goals was similar regardless of the sex of the patient or physician. Selected differences were found in the style of CVD risk factor management by sex of physician and patient.     

Primary care physicians' discussion of emotional distress and patient satisfaction

OBJECTIVES: To assess: a) the prevalence and determinants of self-reported emotional distress in the Israeli population; b) the rate of self-reported discussion of emotional distress with family physicians; and c) the association between such discussions and patient satisfaction with care. METHOD: Design: Retrospective, cross-sectional survey that was conducted through structured telephone interviews in Hebrew, Arabic, and Russian. This study was part of a larger study assessing patients' perceptions of the quality of health services. Participants: A representative sample of 1,849 Israeli citizens aged 22 to 93 (response rate: 84%). Independent variables: Gender, age, ethnicity (spoken language), education, income, self-reported chronic disease, self-reported episode(s) of emotional distress during the last year, and having discussed emotional distress with the family physician. Outcome measure: satisfaction with care. RESULTS: 28.4% reported emotional distress and 12.5% reported discussion of emotional distress with a primary care physician in the past year. Logistic regression identified female gender, Arab ethnicity, low income, and chronic illness as independent correlates of emotional distress. These as well as Russian speakers and having experienced emotional distress during the past year were identified as independent correlates of discussion of emotional distress with the family physician. Patients who reported discussion of emotional distress with their family physician were significantly more satisfied with care. CONCLUSIONS: Encouraging physicians to detect and discuss emotional distress with their patients may increase patient satisfaction with care, and possibly also improve patients' well-being and reduce health care costs.     

The association between inquiry about emotional distress and women's satisfaction with their family physician: findings from a national survey

BACKGROUND: Women appear to be more vulnerable than men to emotional distress (ED) However, ED often goes unrecognized by family physicians. PURPOSE: To (1) assess the rate of inquiry about ED by family physicians and (2) explore the association between physician's inquiry about ED and women's satisfaction with care. METHODS: Telephone interviews were conducted in 2003 using a structured questionnaire in a representative sample of 991 Israeli women aged 22 years or older, with a response rate of 84%. RESULTS: 33% of women reported ED during the past year but only 15% of women reported having discussed ED with their family physician in the last year. Higher rates of discussion of ED with the physician were found among women who had experienced ED (22.5%), those who had a chronic illness (20.1%) had low income (22.7%), and were Arabic (29.5%) or Russian speakers (26.3%). Multivariate analysis indicated that women who had discussed ED with their physician expressed higher satisfaction with the physicians professional level (OR = 6.85), attitude (OR = 2.45), spending enough time (OR = 2.90), and listening to the patient (OR = 3.19), compared with women who had not discussed ED with their physician. CONCLUSIONS: Given the current low rates of inquiry about ED, it appears that developing sensitivity to women's emotional concerns and encouraging physicians to inquire about ED should be given higher priority in medical education at all levels. Furthermore, since inquiry about ED not only improves the appropriateness of care but is also associated with higher satisfaction with the physician, organizations in a competitive health care environment may have a particular interest in promoting this practice.     

Acute renal failure in a patient with prostatic carcinoma. A case of benign uropathy.

Obstructive uropathy and renal insufficiency are often associated with cancer. However, in the case described here, a patient with carcinoma of the prostate had acute renal failure due to benign obstructive uropathy. Precise, prompt diagnosis and treatment resulted in complete reversal of renal symptoms.     

Correlates of quality of life in primary care patients with hypertension

BACKGROUND: Hypertension has been associated with lower levels of quality of life (QoL). However, the specific correlates of lower QoL in this patient population have remained largely unclear. METHODS: A cross-sectional design of 1,125 primary care patients with hypertension. We evaluated demographics, health status, subjective health and mental health, health behaviors, health beliefs, knowledge of hypertension treatment, satisfaction with medical care, and quality of medical care as potential predictors of QoL and perceived QoL in the hypothetical absence of hypertension. RESULTS: Worse financial status, poorer blood pressure control, worse subjective health, mental distress, lack of hypertension diet, and irregular hypertension care were all associated with worse QoL. Worse financial status, poorer blood pressure control, higher body mass index, mental distress, and following a hypertension diet were associated with better QoL in the hypothetical absence of hypertension. CONCLUSIONS: In addition to taking into consideration well known determinants of QoL, such as financial status, health status, and mental health, physicians need to be aware of the potential tradeoff between following medical recommendations that advocate for a strict diet and the impact these have on patients' QoL. Physicians also need to be aware of the effect of imparting information regarding imbalanced blood pressure on perceived QoL.     

Patients' Views of Direct Access to Specialists: An Israeli Experience

Hava Tabenkin, MD, MS; Revital Gross, MA; Shuli Brammli, BA; Pesach Shvartzman, MD

JAMA. 1998;279:1943-1948.

Context.— Surveys carried out among users of medical services can be a useful tool for health care organizations in designing proper services. Specifically, patients' views of direct access to specialists can be useful to health organizations considering the gatekeeper model.

Objective.— To assess patients' opinions about direct access to specialists and referral to specialists through their primary care physician.

Design.— An intercept survey, in which patients were interviewed at the randomly selected service provision sites, was carried out in 3 districts in Israel during 1995. A total of 1445 and 1289 patients were interviewed in primary care and specialty clinics, respectively.

Setting.— Primary care and specialty clinics in 3 regions in Israel serving 750000 members of Kupat Holim Clalit, Israel's largest sick fund.

Participants.— Hebrew-speaking members of Kupat Holim Clalit who visited the primary care or specialty clinics in the 3 regions during the study period.

Main Outcome Measures.— Rate of preferences for direct access to specialists and preferences for referral through primary care physician.

Results.— Fifty-two percent of the respondents preferred direct access to specialists, while 48% preferred a referral from their primary care physician. Multivariate logistic regression analysis indicated that the preference for direct access was significantly lower among patients older than 45 years (odds ratio [OR], 0.75; 95% confidence interval [CI], 0.62-0.91); patients whose primary care physician was a specialist in family medicine (OR, 0.80; 95% CI, 0.67-0.97); and patients who were satisfied with their primary care physician (OR, 0.34; 95% CI, 0.27-0.44). Preference for direct access was significantly higher among more highly educated patients (OR, 1.38; 95% CI, 1.16-1.65) and patients residing in Jerusalem (OR, 2.46; 95% CI, 2.05-2.95) and those younger than 45 years who were dissatisfied with their family physician or a primary care physician who was not board certified. If direct access was not available, 33% of respondents would leave the sick fund and 48% would remain; 19% did not know.

Conclusions.— Informing sick fund members, particularly the younger and more educated among them, about the advantages of consulting with the primary care physician, as well as providing specialty training in family medicine to primary care physicians, may reduce patients' preference for direct access to specialists.

     

A new look at low back complaints in primary care: a RAMBAM Israeli Family Practice Research Network study

BACKGROUND: Low back pain (LBP) is one of the most frequent reasons patients seek consultations in primary care, and it is a major cause of disability. Our research examines the natural history of LBP and the prediction of chronicity in the context of patients presenting to family medicine clinics. METHODS: We performed a prospective cohort study of new episodes of LBP within the framework of a national family practice research network. The setting was 28 primary care family practice clinics located throughout Israel. Of 238 eligible subjects, 219 (92%) completed the study. RESULTS: During the 2-month study period, 2 subjects were referred to the emergency department and discharged, and 2 others were hospitalized. Forty-five percent did not require bed rest, and 38% of the employed were not absent from work. Seventy-one percent showed improvement in functional status; however, only 37% noted complete pain relief. Clinical and demographic data usually did not predict LBP-episode outcomes. The strongest predictors of chronicity were depression, history of job change due to LBP in the past, history of back contusion, lack of social support, family delegitimization of patient's pain, dissatisfaction with first office visit, family history of LBP or other chronic pain, coping style, and unemployment. CONCLUSIONS: The cohort patients displayed a relatively benign natural history of LBP, matched by benign clinical behavior from their physicians. In Israeli primary health care, acute LBP is infrequently associated with hospitalization or prolonged work absenteeism. Although most patients have functional improvement, pain often lingers. Almost all predictors of chronicity are psychosocial.