BACKGROUND: Care of a secondary patient (an individual other than the primary patient for an outpatient visit) is common in family practice, but the content of care of this type of patient has not been described.
METHODS: In a cross-sectional study, 170 volunteer primary care clinicians in 50 practices in the Ambulatory Sentinel Practice Network reported all occurrences of care of a secondary patient during 1 week of practice. These clinicians reported the characteristics of the primary patient and the secondary patient and the content of care provided to the secondary patient. Content of care was placed in 6 categories (advice, providing a prescription, assessment or explanation of symptoms, follow-up of a previous episode of care, making or authorizing a referral, and general discussion of a health condition).
RESULTS: Physicians reported providing care to secondary patients during 6% of their office visits. This care involved more than one category of service for the majority of visits involving care of a secondary patient. Advice was provided during more than half the visits. A prescription, assessment or explanation of symptoms, or a general discussion of condition were provided during approximately 30% of the secondary care visits. Secondary care was judged to have substituted for a separate visit 60% of the time, added an average of 5 minutes to the visit, and yielded no reimbursement for 95% of visits.
CONCLUSIONS: Care of a secondary patient reflects the provision of potentially intensive and complex services that require additional time and are largely not reimbursed or recognized by current measures of primary care. This provision of secondary care may facilitate access to care and represent an added value provided by family physicians.
The family as the unit of care has been a philosophical underpinning of family practice since its inception.1-6 It is common for individual family members to see the same physician and for a family member to be present during a patient’s visit.7-10 Flocke and colleagues11 used direct observation to identify the frequency of care of a secondary patient. They defined a secondary patient as a family member other than the identified patient for an outpatient visit and found that care was provided to a second family member during 18% of the visits. Knishkowry and coworkers12 used self-report by a group of Israeli family physicians to identify a 12% frequency of encounters where 1 or more visitors were simultaneously present. Although Flocke and colleagues focused on the assessment of the effects of these encounters on the primary patient and Knishkowry and coworkers described the number and characteristics of the visitors, neither set of authors described the actual content of care provided to the secondary patient. Our study was designed to describe the profile of services provided to secondary patients during visits to family physicians.
Methods
Sample Selection
Our study was conducted in the Ambulatory Sentinel Practice Network (ASPN), a network of 752 community-based primary care clinicians established in 1982 to conduct practice-based research.13 ASPN’s 122 practices in 34 states and 6 Canadian provinces have been shown to serve a patient population similar to the population of the United States.14 In addition, ASPN clinicians demonstrate practice patterns similar to those reported in the National Ambulatory Medical Survey,15 a national probability sample of visits to office-based physicians in the United States.
All ASPN clinicians were invited to participate in the study by a mailing that briefly described the study and its requirements. A total of 170 clinicians (23% of the total) from 50 member practices (41%) volunteered and completed the data collection.
Study Variables
A secondary patient was defined as another individual (a family member or friend of the primary patient who was either present or absent and was not scheduled for the visit) to whom the clinician offered a discernible service. The primary patient was the patient in the office who registered or signed in for the visit.
The clinician made the determination of whether a discernible service was provided to a secondary patient and reported the type of service using categories that included advice, providing a prescription, assessment or explanation of symptoms, follow-up on previous care, referral to another provider, general discussion of the secondary patient’s condition, and other. More than one service could be checked for a given visit. The categories were developed through input from ASPN clinicians at the network’s annual meeting and through subsequent discussion on the ASPN electronic mailing list.
Participating clinicians reported whether it was the primary patient’s first visit to the practice, who initiated the discussion about the secondary patient, whether the secondary patient was present, the estimated time required to discuss the secondary patient, whether the billing code reflected additional care, and an estimate of whether the care provided to the secondary patient could have substituted for a separate visit. The clinician also reported the age and sex of the primary and secondary patients and their relationship (spouse, parent, son or daughter, sibling, other relative, friend).