Physician recommendation is one of the strongest, most consistent predictors of colorectal cancer (CRC) screening. Little is known regarding characteristics associated with patient adherence to physician recommendations in community and academic based primary care settings.
Data were analyzed from 975 patients, aged 50 and over, recruited from 25 primary care practices in New Jersey. Chi-square and generalized estimate equation (GEE) analyses determined independent correlates of receipt of and adherence to physician recommendation for CRC.
Patients reported high screening rates for CRC (59%). More than three-quarters of patients reported either screening or having received a screening recommendation (82%). Men (P=.0425), non-smokers (P=.0029), and patients who were highly educated (P=.0311) were more likely to receive a CRC screening recommendation. Patients more likely to adhere to CRC screening recommendations were older adults (P<.0001), non-smokers (P=.0005), those who were more highly educated (P=.0365), Hispanics (P=.0325), and those who were married (P<.0001).
Community and academic primary care clinicians appropriately recommended screening to high risk patients with familial risk factors. However, they less frequently recommended screening to others (i.e., women and smokers) also likely to benefit. To further increase CRC screening, clinicians must systematically recommend screening to all patients who may benefit.
We recently completed a strategic planning process to better understand the development of our five-year-old PBRN and to identify gaps between our original vision and current progress. While many of our experiences are not new to the PBRN community, our reflections may be valuable for those developing or re-shaping PBRNs in a changing health care environment.
We learned about the importance of: (1) Shared vision and commitment to a unique patient population; (2) Strong leadership, mentorship, and collaboration; (3) Creative approaches to engaging busy clinicians and bridging the worlds of academia and community practice; (4) Harnessing data from electronic health records and navigating processes related to data protection, sharing, and ownership.
We must emphasize research that is timely, relevant, and integrated into practice. One model supporting this goal involves a broader partnership than was initially envisioned for our PBRN, one which includes clinicians, researchers, information architects and quality improvement experts partnering to develop an Innovation Center. This Center could facilitate development of relevant research questions while also addressing ‘quick-turnaround’ needs.
Gaps remain between our PBRN’s initial vision and current reality. Closing these gaps may require future creativity in partnership building and nontraditional funding sources.
practice-based research; community health; primary care; electronic health records; health care safety net
We aimed (1) to demonstrate the application of national pediatric quality measures derived from claims-based data, for use with Electronic Medical Record (EMR) data, and (2) to determine the extent to which rates differ if specifications were modified to allow for flexibility in measuring receipt of care.
We reviewed EMR data for all patients up to 15 years with≥1 office visit to a safety net family medicine clinic in 2010 (n=1,544). We assessed rates of appropriate well-child visits (WCVs), immunizations, and body mass index (BMI) documentation, defined strictly by national guidelines versus by guidelines with clinically relevant modifications.
Among children <3 years, 52.4% attended ≥6 WCVs by 15 months; 60.8% had ≥6 visits by 2 years. Less than 10% completed 10 vaccination series before their 2nd birthday; with modifications, 36% were up-to-date. Among children aged 3-15 years, 63% had a BMI percentile recorded; 91% had BMI recorded within 36 months of the measurement year.
Applying relevant modifications to national quality measure definitions captured a substantial number of additional services. Strict adherence to measure definitions might miss the true quality of care provided, especially in populations who may have sporadic patterns of care utilization.
quality of health care; child health; Electronic Medical Record; low-income population
Change champions are important for moving new innovations through the phases of initiation, development, and implementation. While research attributes positive healthcare changes to the help of champions, little work provides details on the champion role.
Using a combination of immersion/crystallization and matrix techniques, we analyzed qualitative data from a sample of 8 practices which included field notes of team meetings, interviews, and transcripts of facilitator meetings.
Our analysis yielded insights into the value of having two discrete types of change champions: 1) those associated with a specific project (project champions) and 2) those leading change for entire organizations (organizational change champions). Relative to other practices under study, those that had both types of champions who complemented each other were best able to implement and sustain diabetes improvements. We provide insights into the emergence and development of these champion types, as well as key qualities necessary for effective championing.
Practice transformation requires a sustained improvement effort that is guided by a larger vision and commitment and assures that individual changes fit together into a meaningful whole. Change champions – both project and organizational change champions – are critical players in supporting both innovation-specific and transformative change efforts.
Surveys reveal limited screening and counseling for alcohol misuse by primary care physicians despite evidence-based recommendations. We developed and evaluated an alcohol screening and misuse counseling tool designed to assist clinicians at the point-of-care (POC).
Mixed methods, prospective cohort study conducted in a practice-based research network with licensed clinicians. A software tool was designed to guide clinicians through evidence-based alcohol misuse assessment and interventions.
Participants (N=12) used the tool an average of 3 sessions and 71% were satisfied with the tool. Participants increased their ability to differentiate between patients who are “at risk” drinkers vs. those with alcohol use disorders including dependence/abuse (21%; t=2.4, p=.04). Thematic analysis of interviews suggest that barriers to overall use included perceptions of alcohol use; clinical need to intervene; time; and issues with use of technology generally at the POC. However, the tool added confidence and a valuable framework for interventions and was valued as an educational tool. Users felt that increased training and practice could increase comfort and impact future POC use. Increased POC usability may also be achieved through tool simplification and additional flexibility in POC use options.
A computer-assisted counseling tool for alcohol misuse and abuse can be implemented in primary care settings and shows promise for improving physician screening and interventions for alcohol misuse. To enhance utility in daily clinical practice we recommend design enhancements and strategies to enhance usage as described in this research.
The recent emphasis on improving health literacy highlights the importance of building strong relationships between patients and healthcare providers. Patients perceiving good communication in healthcare settings report better health status. Having a usual source of care (USC) may play a key role in achieving optimal communication between patients and physicians.
To determine if having an identified place for usual care is more often associated with positive patient perceptions about their communication and relationships with healthcare providers.
Cross-sectional descriptive and multivariable analysis of the 2002 Medical Expenditure Panel Survey (MEPS), a nationally representative survey.
Civilian non-institutionalized US population aged ≥18 years who had visited a healthcare provider in the 12 months prior to the survey (N=approximately 16,700).
Respondents perceptions of their physicians’ communication skills, measured in six related survey questions. Responses along a four-point Likert scale were dichotomized into “always” and “not always.”
Approximately 78% of U.S. adults reported having a USC in 2002. Among those who visited a healthcare provider in the 12 months prior to the 2002 MEPS survey, positive patient perceptions about physician communication were significantly associated with having an identified USC. When compared with adults reporting no USC (reference group, OR=1.0), adults with a USC were more likely to report that their providers always listened to them (OR=1.31, 95% CI 1.16-1.48), always explained things so they can understand (OR=1.26, 95% CI 1.13-1.41), always showed respect (OR=1.24, 95% CI 1.10-1.40), and always spent enough time with them (OR=1.20, 95% CI 1.07-1.35). Among those with an identified USC, several demographic factors were associated with patient perceptions of autonomy in making healthcare decisions, including: non-Hispanic ethnicity, private health insurance coverage, having a rural residence, living in a Western census region, and having a higher income.
Patients who have a usual place to go for healthcare needs are more likely to report positive communication and interactions with their healthcare providers. This study suggests that one way to improve communication in healthcare settings is to develop policies and practices to ensure that all patients have consistent access to a usual source of care.
In 2001, community health center (CHC) leaders in Oregon established an organization to facilitate the integration of health information technology, including a shared electronic health record (EHR), into safety net clinics. The Oregon Community Health Information Network (shortened to OCHIN as other states joined) became a CHC information technology hub, supporting a network-wide EHR with one master patient index, now linked across >40 safety net organizations serving >900,000 patients with nearly 8,000,000 distinct CHC visits. Recognizing the potential of OCHIN’s multi-clinic network and comprehensive EHR database for conducting safety net-based research, OCHIN leaders and local researchers formed the Safety Net West practice-based research network (PBRN). The Safety Net West “community-based laboratory,” based at OCHIN, is positioned to become an important resource for many studies including: evaluation of the real-time impact of health care reform on uninsured populations; development of new models of primary care delivery; dissemination and translation of interventions from other EHR-based systems (e.g., Kaiser Permanente) into the community health setting; and analyses of factors influencing disparities in health and health care access. We describe the founding of Safety Net West, its infrastructure development, current projects, and the future goals of this community-based PBRN with a common EHR.
practice-based research; community health; primary care; electronic health records; health care safety net
To examine the prevalence of difficult psychiatrist-patient interactions of 20 psychiatrists in the South Texas Psychiatric PBRN, determine what characteristics were associated with “difficult” patients, and compare findings with previous studies in primary care.
During a 2-month observational study, psychiatrists collected patient information on setting, demographics, diagnoses, medications and rated the patients using a Difficult Doctor Patient Relationship Questionnaire (DDPRQ-10) which had previously been used and validated in the primary care setting.
A total of 905 valid data cards were collected. Difficult patients were identified in 15% of the sample. Diagnoses of schizophrenia, alcohol/substance abuse, and personality disorder were associated with difficulty. Psychiatrists least burdened by difficult patients were older, in solo practice, and worked 51-55 hours per week.
This cross-sectional study demonstrates that psychiatrists encounter difficult patients at a similar rate (15%) as do primary care physicians. Mentoring programs and structured treatment interventions for the most difficult patient groups may assist all physicians who treat psychiatric patients whether in specialty, family medicine, or other primary care settings.
Hot flashes (HFs) are a particularly common and distressing symptom in breast cancer survivors (BCS). Given its low rate of side effects, acupuncture shows promise as a therapeutic approach for HFs but little is known about BCS’s decision-making about use of acupuncture. This study seeks to identify attitudes and beliefs about using acupuncture for HFs by BCS.
Using the Theory of Planned Behavior (TPB) as a conceptual framework, we conducted semi-structured interviews among women with stage I–III breast cancer who had finished primary treatment and were currently experiencing HFs. Interviews were taped, transcribed, and coded. We used a modified grounded theory approach to analyze the data.
Twenty-five BCS (13 Caucasian/12 African American) participated in the study. Respondents stated that their intended use of acupuncture for HFs would be dependent on: 1) Expected therapeutic effects (e.g. pain relief, energy); 2) Practical concerns (e.g. fear of needles, practitioner experience, time commitment); and 3) Source of decision support/validation (e.g. family members, physicians, self). Although constructs in the TPB accounted for many decision factors, respondents identified two major themes outside of the TPB: 1) Viewing acupuncture as a natural alternative to medications, and 2) Assessing the degree of HFs as bothersome enough in the context of other medical co-morbidities to trigger the need for therapy.
BCS expressed varied expected therapeutic benefits, practical concerns, and decision support, emphasizing the “natural appeal” and symptom appraisal as key determinants in using acupuncture for HFs. Incorporating these factors in counseling BCS may promote patient-centered communication leading to improved hot flash management and quality of life.
There is little evidence to document patient satisfaction with follow up care provided by family physicians/general practitioners (FP/GP) to breast cancer patients. We aimed to identify determinants of satisfaction with such care in low-income medically underserved women with breast cancer.
Cross sectional study of 145 women who reported receiving follow up care from a FP/GP. Women were enrolled in California’s Breast and Cervical Cancer Treatment Program and were interviewed by phone 3 years after breast cancer diagnosis. Cleary and McNeil’s model, which states that patient satisfaction is a function of patient characteristics, structure of care, and processes of care, was used to understand the determinants of satisfaction. Stepwise logistic regression was used to identify significant predictors.
73.4% reported that they were extremely satisfied with their treatment by the family physician/general practitioner. Women who were able to ask their family physicians questions about their breast cancer had six times greater odds of being extremely satisfied compared to women who were not able to ask any questions. Women who scored the family physician higher on the ability to explain things in a way she could understand had a higher odds of being extremely satisfied compared to women who scored their family physicians lower.
FP/GPs providing follow up care for breast cancer patients should encourage patients to ask questions, and must communicate in a way that patients understand. These recommendations are congruent with the characteristics of patient centered communication for cancer patients enunciated in a recent NCI monograph.
family physician; breast cancer; satisfaction
Intimate partner violence (IPV) victims frequently seek medical treatment though rarely for IPV. Recommendations for health care providers (HCPs) include: IPV screening, counseling, and safety referral.
Report women’s experiences discussing IPV with HCPs.
Structured interviews with women reporting IPV HCP discussions; descriptive analyses; bivariate and multivariate analyses and association with patient demographics and substance abuse.
Women from family court, community-based, inner-city primary care practice, and tertiary care-based outpatient psychiatric practice.
A total 142 women participated: family court (N=44; 31%), primary care practice (N=62; 43.7%), and psychiatric practice (N=36; 25.4%) Fifty-one percent (n=72) reported HCPs knew of their IPV. Of those, 85% (n=61) told a primary care provider. Regarding IPV attitudes, 85% (n=61) found their HCP open, and 74% (n=53) knowledgeable. Regarding approaches, 71% (n= 51) believed their HCP advocated leaving the relationship. While 31% (n=22) received safety information, only 8% (n=6) received safety information and perceived their HCP as not advocating leaving the abusive relationship.
Half of participants disclosed IPV to their HCP’s but if they did, most perceived their provider advocated them leaving the relationship. Only 31% reported HCPs provided safety planning despite increased risks associated with leaving. We suggest healthcare providers improve safety planning with patients disclosing IPV.
domestic violence; patient-physician communication; women’s health
The patient-centered medical home (PCMH) concept has recently garnered national attention as a means of improving the quality of primary care. Preventive services are one area where the PCMH is hoped to achieve gains, though there has been limited exploration of PCMH characteristics that can assist with practice redesign.
To examine whether first-contact access characteristics of a medical home (e.g., availability of appointments or advice by telephone) confer additional benefit in the receipt of preventive services for individuals already in a longitudinal relationship with a usual primary care physician at a site of care.
Secondary analysis examining data from 5,507 insured adults with a usual physician who participated in the 2003–2006 round of the Wisconsin Longitudinal Survey. Using logistic regression, we calculated the odds of receiving each preventive service, comparing individuals who had first-contact access to those without first-contact access.
Eighteen percent of the sample received care with first-contact access. In multivariable analyses, after adjustment, individuals who had first-contact access had higher odds of having received a prostate exam (OR 1.62; 95% CI 1.20–2.18), a flu shot (OR 1.36; 95% CI 1.01–1.82) and a cholesterol test (OR 1.36; 95% CI 1.01–1.82) in the past year. There was no significant difference in receipt of mammograms (OR 1.23; 95% CI 0.94–1.61).
In the primary care home, first-contact accessibility adds benefit beyond continuity of care with a physician in improving receipt of preventive services. Amid increasing primary care demands and finite resources to translate the PCMH into clinic settings there is need for further studies of the interplay between specific PCMH principles and how they perform in practice.
patient-centered medical home; preventive medicine; access to care; continuity of care; primary care; quality improvement
Motivational Interviewing (MI) is used to help patients change their behaviors. We sought to determine if physician use of specific MI techniques increases patient satisfaction with the physician and perceived autonomy.
We audio-recorded preventive and chronic care encounters between 40 primary care physicians and 320 of their overweight or obese patients. We coded use of MI techniques (eg, empathy, reflective listening). We assessed patient satisfaction and how much the patient felt the physician supported him or her to change. Generalized estimating equation models with logit links were used to examine associations between MI techniques and patient perceived autonomy and satisfaction.
Patients whose physicians were rated as more empathic had higher rates of high satisfaction than patients whose physicians were less empathic (29% vs 11%; P = .004). Patients whose physicians made any reflective statements had higher rates of high autonomy support than those whose physicians did not (46% vs 30%; P = .006).
When physicians used reflective statements, patients were more likely to perceive high autonomy support. When physicians were empathic, patients were more likely to report high satisfaction with the physician. These results suggest that physician training in MI techniques could potentially improve patient perceptions and outcomes.
Counseling; Empathy; Patient Satisfaction; Reflective Listening
Quality improvement collaboratives (QICs) are used extensively to promote quality improvement in healthcare. Evidence of their effectiveness is limited, prompting calls to open up the ‘black box’ to better understand how and why such collaboratives work.
We selected a cohort of five primary care practices that participated in a six-month intervention study aimed at improving colorectal cancer screening rates. Using an immersion/crystallization technique, we analyzed qualitative data which included audio-recordings and fieldnotes of QICs and practice-based team meetings.
Three themes emerged from our analysis. 1) Practice staff became empowered through and drew on the QICs to advance change efforts in the face of leader/physician resistance. 2) A mix of content and media in a QIC program was important for reaching all participants. 3) Resources offered at the QIC did little to spur practice change efforts.
QICs offer a potentially powerful way of disseminating healthcare innovations through enhanced strategies for learning and change. Creating collaborative environments where diverse participants learn, listen, reflect, and share together can enable them to take key messages and change strategies back to their own organizations that benefit them the most.
Patients receive care in safety net clinics regardless of insurance status; however, diabetes preventive care receipt might vary in patients with differing levels of insurance continuity.
In a retrospective cohort study, using electronic health record data from adults with diabetes receiving care in 50 safety net clinics in Oregon in 2005–2007, we conducted adjusted logistic regressions to model the associations between amount of time with insurance and rates of receipt of lipid screening, influenza vaccination, nephropathy screening (urine microalbumin), and DM control (glycosylated hemoglobin) screening.
Of 3,384 adults with diabetes, 711 were ‘partially’ insured (covered 1–99% of the 3-year study period), 909 had no coverage, and 1,764 were continuously insured. In adjusted models, persons with partial or no coverage during the 3-year study period were less likely to receive most preventive services, compared to those with continuous coverage. We found no evidence of a dose-response relationship with increasing duration of coverage, nor of a threshold amount of partial coverage, associated with better receipt of care.
Safety net clinic patients need both access to primary care and continuous insurance. All patients with partial coverage, regardless of the extent of time with insurance, had lower odds of receiving preventive care.
diabetes care; discontinuous health insurance coverage; health policy; safety net populations; electronic health record data
The purpose of this paper is to explore the concept of information chaos as it applies to the issues of patient safety and physician workload in primary care and to propose a research agenda.
We use a human factors engineering perspective to discuss the concept of information chaos in primary care and explore implications for its impact on physician performance and patient safety.
Information chaos is comprised of various combinations of information overload, information underload, information scatter, information conflict, and erroneous information. We provide a framework for understanding information chaos, its impact on physician mental workload and situation awareness, its consequences, discuss possible solutions and suggest a research agenda which may lead to methods to reduce the problem.
Information chaos is experienced routinely by primary care physicians. This is not just inconvenient, annoying and frustrating; it has implications for physician performance and patient safety. Additional research is needed to define methods to measure and eventually reduce information chaos.
Primary Health Care; Information Management/Informatics; Complexity Science; Medical Errors; Practice Management
Evaluating effective growth and development of a Practice-Based Research Network (PBRN) can be challenging. The purpose of this article is to describe the development of a logic model and how the framework has been used for planning and evaluation in a primary care PBRN.
An evaluation team was formed consisting of the PBRN directors, staff and its board members. After the mission and the target audience were determined, facilitated meetings and discussions were held with stakeholders to identify the assumptions, inputs, activities, outputs, outcomes and outcome indicators.
The long-term outcomes outlined in the final logic model are two-fold: 1.) Improved health outcomes of patients served by PBRN community clinicians; and 2.) Community clinicians are recognized leaders of quality research projects. The Logic Model proved useful in identifying stakeholder interests and dissemination activities as an area that required more attention in the PBRN. The logic model approach is a useful planning tool and project management resource that increases the probability that the PBRN mission will be successfully implemented.
Quantify the prevalence, measure the severity, and describe treatment patterns in patients who present to medical clinics in Texas with community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) skin and soft-tissue infections (SSTI).
Ten primary care clinics participated in this prospective, community-based study. Clinicians consented patients and collected clinical information, pictures, and wound swabs; data were processed centrally. MRSASelect™ was used for identification. Susceptibilities were determined via Etest®.
Overall, 73/119 (61%) patients presenting with SSTIs meeting eligibility requirements had CA-MRSA. Among these, 49% were male, 79% were Hispanic, and 30% had diabetes. Half (56%) of the lesions were ≥ 5 cm in diameter. Most patients had abscesses (82%) and many reported pain scores of ≥ 7/10 (67%). Many presented with erythema (85%) or drainage (56%). Most received incision and drainage (I&D) plus an antibiotic (64%). Antibiotic monotherapy was frequently prescribed: trimethoprim-sulfamethoxazole (TMP-SMX) (78%), clindamycin (4%), doxycycline (2%), and mupirocin (2%). The rest received TMP-SMX in combination with other antibiotics. TMP-SMX was frequently administered as one double-strength tablet twice daily. Isolates were 93% susceptible to clindamycin and 100% susceptible to TMP-SMX, doxycycline, vancomycin, and linezolid.
We report a predominance of CA-MRSA SSTIs, favorable antibiotic susceptibilities, and frequent use of TMP-SMX in primary care clinics.
There is uncertainty regarding Hispanic individuals' depression treatment preferences, particularly regarding antidepressant medication, the most available primary care option. We assessed whether this uncertainty reflected heterogeneity among subgroups of Hispanic persons and investigated possible mechanisms. Specifically, we examined factors associated with medication preferences in non-Hispanic white, and Spanish-speaking and English-speaking Hispanic persons.
We analyzed data from a follow-up telephone interview of 839 non-Hispanic white and 139 Hispanic respondents originally surveyed via the 2008 California Behavioral Risk Factor Surveillance System. Measures included treatment preferences (for treatment plans including versus not including antidepressants); depression history and current symptoms; socio-demographics; and psychological measures.
Compared to non-Hispanic white respondents (adjusting for age, gender, history of depression diagnosis, and current depression symptoms), Spanish-speaking Hispanic (adjusted odds ratio [AOR] = 0.41, 95% Confidence Interval [CI] 0.19 - 0.90) but not English-speaking Hispanic (AOR = 1.18, 95% CI 0.60-2.33) respondents had a lower preference for antidepressant inclusive options. Endorsing a biomedical explanation of depression was associated with a preference for antidepressant inclusive options (AOR = 4.76, 95% CI 3.13 - 7.14) for all respondents and accounted for the effect of Spanish language interview. Accounting for other factors did not change these relationships, although older age and history of depression diagnosis remained significant predictors of antidepressant inclusive treatment preference for all respondents.
Spanish language interview and less belief in a biomedical explanation for depression, not ethnicity, were associated with Hispanic respondents' lower preferences for pharmacologic treatment of depression. Understanding treatment preferences and illness beliefs could help optimize depression treatment in primary care.
Hispanic; depression treatment preferences; illness representation models
Women with intellectual disabilities have the same rate of breast cancer as other women but are less likely to undergo screening mammography. Characteristics associated with mammography for women with intellectual disabilities in the US are unknown.
Secondary data analysis of Massachusetts Department of Developmental Services database, comparing women who had a mammogram within 2 years with women who had not on variables related to the ecological model. Bivariate analyses, logistic regression, and assessment of interactions were performed.
The study sample’s (n=2907) mean age was 54.7 years; 58% lived in 24-hour residential settings, 52% received nursing health coordination, and over 25% had clinical exam needs (e.g. sedation). Residential setting, health coordination, and recent influenza vaccination were all associated with mammography. Having a guardian, higher level of activities of daily living (ADL) needs, and exam needs (requiring sedation or limited wait time for exams) were associated with lower rates. Interactions between health coordination and exam needs confirmed the potential of the nurse to ameliorate barriers to mammography.
Several system-level variables were significantly associated with mammography and, in some cases, appeared to ameliorate intrapersonal/behavioral barriers to mammography. Community agencies caring for intellectually disabled women have potential to impact mammography by using health coordination.
Shared medical appointments (SMAs) are 90-minute group appointments for patients with similar medical complaints. SMAs include components of a traditional office visit but provide further emphasis on health education. The effectiveness of SMAs on weight-loss in an outpatient setting has not been studied.
Weight-loss SMAs were offered by one physician at the Palo Alto Medical Foundation. Teaching content included Diabetes Prevention Program materials. This analysis includes patients who attended at least one SMA (n = 74) compared with patients in the same physician’s practice who had at least one office visit and a body mass index ≥25 kg/m2 (n = 356).
The SMA group had a higher proportion of women than the comparison group (76% vs 64%) and were older (mean, 52.4 years; SD, 13.1 years vs mean, 47.0 years; SD, 13.3 years). SMA patients on average lost 1.0% of their baseline weight. Patients in the comparison group on average gained 0.8% of their baseline weight.
SMAs may be a viable option for physicians to promote weight loss in the clinical setting.
Overweight; Patient Appointments; Weight Loss
Having a strong relationship with a personal physician can improve patient health outcomes. Yet, achieving and sustaining this type of patient-physician relationship is often not possible in the current American health care system. Pisacano scholars and alumni, a group of young physician leaders supported by the American Board of Family Medicine (ABFM), gathered for a two-day symposium in June 2010 to explore the meaning of personal doctoring and its importance to our work as family physicians. Using the techniques of Appreciative Inquiry, the group discussed three questions: “What is it like to have a personal physician? What is it like to be a personal physician? What are some feasible next steps toward making this possible?” Symposium participants concluded that achieving the ideal patient-physician relationship for all patients and physicians would involve extensive alterations to the current health care system beyond what is outlined in the 2010 Patient Protection and Affordable Care Act. However, in the context of current health reform efforts, individual physicians, researchers, and policy makers must not lose sight of the importance of the patient-physician relationship and should continue to take concrete steps on an individual and system level to move us closer to this ideal.
personal doctoring; physician-patient relationships; physician-patient interactions; continuity of care; patient-centered care
To examine the relationship between patients’ English proficiency, patient-provider language concordance, and health care quality among foreign-born Latinos in the United States.
National probability sample data (from the Pew Hispanic Center/Robert Wood Johnson Foundation Latino Health Survey) were analyzed from telephone interviews with foreign-born Latino adults (n = 2921; aged 18 years and older). There were 3 main outcomes related to clinical experiences using self-reports of confusion, frustration, and perception of poor quality of care received because of English-speaking ability and accent bias, as well as an overall rating of care quality. Patients’ English proficiency and patient-provider language concordance were the chief predictors.
Patients’ English proficiency was not significantly associated with the 3 clinical experiences measures and marginally so with overall care quality ratings. Language concordance was significantly associated with a lower likelihood of confusion, frustration, and language-related poor quality ratings, and was positively associated with patient-reported overall quality of care. In addition, providers’ language concordance attenuated the statistical significance of the effects of patients’ English proficiency when both were modeled simultaneously.
Patient-provider language concordance plays an important role in communication barriers among foreign-born Latino patients. Our findings indicate that although patients’ language proficiency is important to health care quality ratings, what may matter more is when patient and provider speak the same language.
Quality of Health Care; Latinos; Hispanics; Language; Cross-Cultural Issues
To describe the differential completion rates and cost of sequential methods for a survey of adolescent regional healthcare delivery organization enrollees.
4000 randomly selected enrollees were invited to complete a mailed health survey. Techniques used to boost response included: 1) a follow-up mailing 2) varying the appearance of the survey 3) reminder calls 4) phone calls to obtain parent and child consent and administer the survey. We evaluated the outcome and costs of these methods.
783 (20%) enrollees completed the 1st mailed survey, and 521 completed the 2nd, increasing the overall response rate to 33%. Completion was significantly higher for respondents who received only the plain survey than those receiving only the color (p<.001). Reminder calls boosted response by 8%. Switching to phone survey administration boosted response by 20% to 61%. The cost per completed survey was $29 for the first mailing, $26 after both mailings, $42 for mailings and reminder calls, and $48 for adding phone surveys.
The response to mailings and reminder calls was low and the cost high, with decreasing yield at each step, though some low cost techniques helpful. Results suggest phone surveys may be most effective among similar samples of adolescents.