Patient Care Outside of Office Visits: A Primary Care Physician Time Study.
J Gen Intern Med. 2010 Sep 2;
Authors: Chen MA, Hollenberg JP, Michelen W, Peterson JC, Casalino LP
BACKGROUND: Patient care provided by primary care physicians outside of office visits is important for care coordination and may serve as a substitute for office visits. OBJECTIVES: To describe primary care physicians’ ambulatory patient care activities outside of office visits (“AOVs”) and their perceptions of the extent to which AOVs substitute for visits and may be performed by support staff. DESIGN: Cross-sectional direct observational study. PARTICIPANTS: Thirty-three general internists in 20 practices in two health care systems (one public, one private) in the New York metropolitan area. MAIN MEASURES: Duration of AOVs by type of activity and whether they pertain to a patient visit on the study day (visit specific) or not (non-visit specific). Physician perceptions of the: (1) extent that non-visit-specific AOVs substitute for visits that would have otherwise occurred, (2) extent that visits that occurred could have been substituted for by AOVs, and (3) potential role of support staff in AOVs. KEY RESULTS: Physicians spent 20% of their workday performing AOVs, 62% of which was for non-visit specific AOVs. They perceived that a median of 37% of non-visit-specific AOV time substituted for visits, representing a potential five visits saved per day. They also perceived that 15% of total AOV time (excluding charting) could be performed by support staff. Forty-two percent of physicians indicated that one or more visits during the study day could be substituted for by AOVs. CONCLUSIONS: Though time spent on AOVs is generally not reimbursed, primary care general internists spent significant time performing AOVs, much of which they perceived to substitute for visits that would otherwise have occurred. Policies supporting physician and staff time spent on AOVs may reduce health care costs, save time for patients and physicians, and improve care coordination.
20811956
– Patient Care Outside of Office Visits: A Primary Care Physician Time Study.
Patient resistance towards diagnosis in primary care: Implications for concordance.
Health (London). 2010 Sep;14(5):505-22
Authors: Ijäs-Kallio T, Ruusuvuori J, Peräkylä A
This article reports a conversation analytic study of patients’ resisting responses after doctors’ diagnostic statements. In these responses, patients bring forward information that confronts the doctor’s diagnostic information. We examine two turn formats – aligning and misaligning – with which patients initiate resistance displays, and describe conversational resources of resistance the patients resort to: their immediate symptoms, their past experiences with similar illness conditions, information received in past medical visits and their diagnostic expectations that have been established earlier in the consultation.Through the deployment of these resources, patients orient to the doctor’s diagnostic information as negotiable and seek to further a shared understanding with the doctor on their condition. The results are discussed with regard to concordance as a process in which patients and doctors arrive at a shared understanding on the nature of the illness and its proper treatment. Our analysis illuminates the mechanisms in interaction in and through which concordance can be realized. Thus, we suggest that concordance can be seen to encompass not only treatment discussion but also the process where participants reach agreement about the diagnosis. The data of the study consist of 16 sequences of patients’ resisting responses to diagnosis and is drawn from 86 Finnish primary care visits for upper respiratory tract infections.
20801997
– Patient resistance towards diagnosis in primary care: Implications for concordance.
Contributions of prognostic factors for poor outcome in primary care low back pain patients.
Eur J Pain. 2010 Aug 19;
Authors: Dunn KM, Jordan KP, Croft PR
BACKGROUND: Back pain is common and some sufferers consult GPs, yet many sufferers develop persistent problems. Combining information on risk of persistence and prognostic indicator prevalence provides more information on potential intervention targets than risk estimates alone. AIMS: To determine the proportion of primary care back pain patients with persistent problems whose outcome is related to measurable prognostic factors. METHODS: Prospective cohort study of back pain patients (30-59years) at five general practices in Staffordshire, UK (n=389). Baseline factors (demographic; episode duration; symptom severity; pain widespreadness; anxiety; depression; catastrophising; fear-avoidance; self-rated health) were assessed for their association with disabling and limiting pain after 12-months. The proportion of those with persistent problems whose outcome was related to each factor was calculated. RESULTS: Prevalence of prognostic factors ranged from 23% to 87%. Strongest predictors were unemployment (adjusted relative risk (RR) 4.2; 95% CI 2.0, 8.5) and high pain intensity (4.1; 1.7, 9.9). The largest proportions of persistent problems were related to high pain intensity (68%; 95% CI 27, 87%) and unemployment (64%; 33, 82%). Combining these indicated that 85% of poor back pain outcome is related to these two factors. Poor self-rated health, functional disability, upper body pain and pain bothersomeness were related with outcome for over 40% of those with persistent problems. CONCLUSIONS: Several factors increased risk of poor outcome in back pain patients, notably high pain and unemployment. These risks in combination with high prevalence of risk factors in this population distinguish factors that can help identify targets or sub-groups for intervention.
20728385
– Contributions of prognostic factors for poor outcome in primary care low back pain patients.
