Although an average of three preventive health services that patients were eligible and due for at the time of a PHE were delivered, almost as many services went undelivered. While the opportunity to deliver breast cancer, colorectal cancer, and hypertension screening was rarely missed, delivery of aspirin and diet counseling, influenza immunization, and vision and hearing screening was achieved less than one third of the time. These results are generally consistent with previous findings of preventive service delivery in primary care11,31,32
and for the first time begin to highlight the multilevel factors associated with delivery of preventive services when a patient is due at the time of PHE.
Preventive service delivery33,34
and care quality35,36
have been found to be a function of the interaction among patient, physician, practice, and other environmental factors,37, 38
yet many prior studies have focused on patient factors alone or only a limited number of other factors.39–43
When controlling for a broad range of factors, this study found at the patient level an association of service delivery only with decreasing patient age and increasing BMI. This latter finding is consistent with a handful of other recent studies that have found obese patients to be as or more likely to receive appropriate preventive services compared to others.44–46
Previous studies have also found that physician gender influences preventive service delivery.41,43
While this study did not find that physician gender alone affected preventive service recommendation and delivery, preventive service delivery was jeopardized when physicians were not of the same gender as their patient. Although other studies have shown gender concordance to be unrelated to service delivery,41,43
the difference may be that this study credited physicians for both recommendation and delivery, or because credit was given for what happened during the visit and not how up-to-date the patient was at presentation.
Prior encounters may influence service delivery as well; patients who had seen their physicians in the past 12 months had fewer services delivered, consistent with previous findings that patient–physician familiarity seems to decrease attention to preventive service delivery.47
The relationship of communication behaviors and prior patient–physician relationship to the recommendation for and delivery of evidence-based preventive care warrants further investigation.
Unexpectedly, preventive services were less likely to be recommended or delivered during visits where the physician accessed the EMR in the exam room. In this study setting, approximately half of the 19 preventive services studied are prompted in the EMR. While these prompted services are generally more likely to be delivered compared to the other services considered, there was no interaction between EMR use in the exam room and whether or not the EMR contained a prompt for the specific service.
Previous studies have found mixed results on whether tools or aids are associated with preventive service outcomes, although most studies have found positive results.37,48,49
As prompted services do not represent a random subset of services (e.g., they are more likely to be linked to performance measures), it is difficult to disentangle exactly what is at play. Although recent studies have generally indicated that using the EMR in the exam room has either neutral or positive effects on patient satisfaction and patient–physician communication,50–53
studies assessing whether using the EMR has adverse effects on preventive service delivery or how the presence of EMR prompts for some services may affect the delivery of a broad range of preventive services have not been conducted.
This study also points to what is likely a complex relationship between visit length and the delivery of preventive health services. Because of the likely endogeneity between visit length and service delivery, the association between the two could not formally be tested. Nonetheless, descriptive findings point to increased service delivery with increasing visit time – but only to a point. After a visit reached 25–29 minutes, service delivery then decreased with additional minutes. This trend suggests that although time spent with the patient may be associated with preventive service delivery up to a certain visit length, other factors — such as competing demands19,54
—are likely at play during longer visits. Service delivery also decreased with each additional concern (negative affect or emotions) that a patient expressed. It may be that patient expressions of concern are reflective of competing health demands that end up taking precedence over routine preventive service discussions.
Study findings also indicate that with each additional minute past the scheduled appointment time that a physician first presents to the exam room, the likelihood of service delivery increased. A priori, it was hypothesized that physicians who presented later might spend less time on preventive services in order to keep on schedule. This does not seem to be the case. Instead it seems likely that some physicians run behind schedule because they are more thorough in their delivery of preventive services.
Lack of time has previously been suggested as a barrier to preventive service delivery, with one study estimating that physicians would need over 21 hours per day to address all their patient’s preventive service needs.13
In this setting, where patients were eligible and due for the receipt of over five evidence-based preventive health services at the time of presentation, time constraints likely forced both physicians and patients to make choices about what topics to address. Results here indicate that physicians seem to prioritize cancer screening over counseling services and immunizations. While many such cancer screenings have the highest opportunity in terms of cost effectiveness and reduction of clinical burden, so too do some counseling services (e.g., aspirin use) that were frequently missed.55
Continuing to rely on face-to-face time between patients and physicians as the primary mode for preventive service delivery will continue to result in less than optimal service delivery. Further, given patient preferences for shared decision making,20,56
increased calls for shared decision making57
as well as the likelihood that technologic advances will make screening decisions more complex, alternative delivery models are clearly needed. Practice redesign approaches are emerging that may be able to better provide cost-effective preventive care in a more comprehensive manner by mobilizing resources both within and outside the exam room.
The patient-centered medical home is one such emerging approach (www.pcpcc.net/files/PilotGuidePip.pdf
). A recent demonstration project used a reduction in practice size, a team approach, and enhanced use of a personal health record and patient outreach/communication to produce gains in care quality, including preventive service delivery.58,59
) Personal health records in particular have shown promise in this area. Although personal health records are often lacking in terms of ideal functionality,60
) preliminary studies have shown that patients using even a basic interactive personal health record that interfaces with an EMR are more up to date on preventive care (www.ahrq.gov/about/annualconf10/krist_rosenthal/krist.HTM
). Finally, population-based approaches such as mailed reminders and automated telephone calls have been shown to improve preventive screenings.61–63
This study has some important limitations and considerations. First, the use of direct observation may have led physicians to deliver preventive services differently. However, this effect is likely small64–66
and, if anything, service delivery would have likely increased under a watchful eye. Second, a relatively broad definition of service recommendation/delivery was used. Thus, although office visit audio-recordings are arguably the prevailing gold standard to measure service delivery,67
service delivery may be overstated as quantity, not quality, of recommendations was measured. Likewise, only one visit was considered; arguably service delivery occurs over a series of visits.
Further, although aspects of patient communication style were assessed, aspects of physician communication beyond the subject matter covered were not considered. It should also be noted that the parent study context may have affected screening discussions, either with respect to colorectal cancer screening (the primary target of the project) or for preventive services overall. Physicians were informed only that the study purpose was to examine general preventive service delivery.
Finally, all physician participants were salaried and patients were all insured, of relatively high income, and in fairly good health. The setting was limited to one integrated delivery system with relatively sophisticated performance measurement and electronic data capture capabilities, and data on preventive service performance improvement initiatives ongoing at the time of the study were not collected. As such, care needs to be taken when generalizing these findings to other populations and settings.
Although an average of three eligible and due preventive services were delivered during each PHE, 2.5 services represented missed opportunities for care. It is notable that several of the services most likely to go undelivered represent substantial opportunities not only to decrease the clinically preventable burden of disease but also to improve the cost effectiveness of care delivered.55
These findings highlight factors associated with missed and delivered services that span multiple levels and identify potential targets for efforts to ensure the delivery of evidence-based preventive services. Future studies should address other factors that may be associated with care delivery, such as physician communication processes and service characteristics as well as examine the potential for emerging practice redesign approaches to improve the delivery of evidence-based preventive services.