Addressing Multiple Problems in the Family Practice Office Visit

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Original Research

Addressing Multiple Problems in the Family Practice Office Visit

J Fam Pract. 2001 March;50(3):211-216

References

1. Stange KC, Jaén CR, Flocke SA, Miller WL, Crabtree BF, Zyzanski SJ. The value of a family physician. J Fam Pract 1998;46:363-68.

2. Jaén CR, Stange KC, Nutting PA. The competing demands of primary care: a model for the delivery of clinical preventive services. J Fam Pract 1994;38:166-71.

3. Stange KC, Flocke SA, Goodwin MA. Opportunistic preventive service delivery: are time limitations and patient satisfaction barriers? J Fam Pract 1998;46:419-24.

4. Callahan EJ, Jaén CR, Goodwin MA, Crabtree BF, Stange KC. The impact of recent emotional distress and diagnosis of depression or anxiety on the physician-patient encounter in family practice. J Fam Pract 1998;46:410-18.

5. Medalie JH, Zyzanski SJ, Goodwin MA, Stange KC. Two physician styles of focusing on the family. J Fam Pract 2000;49:209-15.

6. Medalie JH, Zyzanski SJ, Langa DM, Stange KC. The family in family practice: is it a reality? Results of a multi-faceted study. J Fam Pract 1998;46:390-96.

7. Flocke SA, Goodwin MA, Stange KC. The effect of a secondary patient on the family practice visit. J Fam Pract 1998;46:429-34.

8. Kravitz RL, Bell RA, Franz CE. A taxonomy of requests by patients (TORP): a new system for understanding clinical negotiation in office practice. J Fam Pract 1999;48:872-78.

9. Marvel MK, Epstein RM, Flowers K, Beckman HB. Soliciting the patient’s agenda: have we improved? JAMA 1999;281:283-87.

10. Korsch B, Putnam SM, Frankel R, Roter D. An overview of research on medical interviewing. In: Lipkin M, Putnam S, Lazare A, eds. The medical interview. New York, NY: Springer; 1995.

11. Inui TS, Carter WB. A guide to the research literature on doctor/patient communication. In: Lipkin M, Putnam S, Lazare A, eds. The medical interview. New York, NY: Springer; 1995.

12. Callahan EJ, Bertakis KD. Development and validation of the Davis Observation Code. Fam Med 1991;23:19-24.

13. Stange KC, Zyzanski SJ, Jaén CR, et al. Illuminating the black box: a description of 4454 patient visits to 138 family physicians. J Fam Pract 1998;46:377-89.

14. Crabtree BF, Miller WL, Aita V, Flocke SA, Stange KC. Primary care practice organization: a qualitative analysis. J Fam Pract 1998;46:403-09.

15. Miller WL, Crabtree BF. Clinical research: a multimethod typology and qualitative roadmap. In: Crabtree BF, Miler WL, eds. Doing qualitative research. 2nd ed. Thousand Oaks, Calif: Sage; 1999.

16. Institute of Medicine. Primary care: America’s health in a new era. Donaldson YK, Lohr KN, Vanselow NA, eds. Washington, DC: National Academy Press; 1996.

17. Institute of Medicine. Defining primary care: an interim report. Washington, DC: National Academy Press; 1994.

18. Institute of Medicine. Report of a study: a manpower policy for primary health care. Washington, DC: National Academy of Sciences, Institute of Medicine, Division of Health Manpower and Resource Development; 1978.

19. Starfield B. Primary care: concept, evaluation, and policy. New York, NY: Oxford University Press; 1992.

20. Starfield B. Primary care: balancing health needs, services and technology. New York, NY: Oxford University Press; 1998.

21. Rosenblatt RA, Cherkin DC, Schneeweiss R, Hart LG. The content of ambulatory medical care in the United States: an interspecialty comparison. N Engl J Med 1983;309:892-97.

22. Blumenthal D, Causino N, Chang Y, et al. The duration of ambulatory visits to physicians. J Fam Pract 1999;48:264-71.

23. Lasker RD, Marquis MS. The intensity of physicians’ work in patient visits. N Engl J Med 1999;341:337-41.

24. Iezzoni LI. The demand for documentation for Medicare payment. N Engl J Med 1999;341:365-67.

25. Braun P, Dunn DL. Reimbursement for evaluation and management services. N Engl J Med 1999;341:1619-20.

26. Reynolds RD. Reimbursement for evaluation and management services. N Engl J Med 1999;341:1621.

27. Hurdle S, Pope GC. Improving physician productivity. J Ambulatory Care Manage 1989;12:11-26.

28. Camasso MJ, Camasso AE. Practitioner productivity and the product content of medical care in publicly supported health centers. Soc Sci Med 1994;38:733-48.

29. Chao J, Gillanders WR, Flocke SA, Goodwin MA, Kikano GE, Stange KC. Billing for physician services: a comparison of actual billing with CPT codes assigned by direct observation. J Fam Pract 1998;47:28-32.

On average, 8 (SD=4.5) physician actions were observed per encounter Table 2. Physicians performed an average of 3.3 (SD=1.2) actions per problem. The most common physician actions were questioning (77%), physical examination (49%), prescription writing (32%), providing advice (31%), and reassurance (25%). Of the 452 additional problems raised, only 3% of problems were ignored, and 6% were deferred to another visit.

The association of the number of problems addressed with the duration of the visit was assessed by analysis of variance and a test for linear trend. As shown in Figure 1, the duration of the visit increased approximately 2.5 minutes for each additional problem addressed (P <.001 for linear trend). The visit duration within each of the number of problem groups varied greatly as indicated by the large range for each group; however, the SD for each of the groups as indicated by the shaded bars are a similar size for each of the groups (Levene’s test of equality of error variance=1.48, P=.195).

The concordance between the number of problems observed and the number of problems on the billing sheet was modest, with a trend toward billing for fewer problems than were observed. As shown in Figure 2, 29% of encounters represented a match between the number of problems observed and the number of problems on the billing sheet. Fifty-eight percent of the encounters had more problems observed than recorded on the billing sheet. A much smaller proportion of encounters recorded more problems on the billing sheet than were observed during the encounter.

Discussion

Our exploratory study suggests that it is common for multiple problems to be addressed during visits to a family physician regardless of the initial reason for the visit. Additional problems are raised by both physicians and patients and are rarely deferred or ignored by the physician. Although the phenomenon of integrating a broad health agenda and addressing multiple problems during a single outpatient visit may be well known by practicing community-based family physicians, it may not be recognized by policymakers or health services researchers whose window into the process of outpatient care is provided by the medical record and billing data.

Addressing the majority of a patient’s health care needs and providing comprehensive care is a core feature of quality primary care.^16-20 Previous work has documented the wide range of diagnoses and clusters of diagnoses that family physicians commonly address during outpatient care.^13,21 However, truly comprehensive care goes beyond providing a broad array of services; it also involves the integration of care in a physician-patient relationship context. Prioritizing, providing, and orchestrating care for acute and undifferentiated illness, chronic disease, preventive services, and mental health care represents a key feature of primary care practice such that the care is greater than the sum of its individual commodities.¹ These data suggest that single visits often address a broad agenda of health care.

Overall, as the number of problems increase so does the length of the visit. Others have found that ordering or performing more tests, providing preventive services, and conducting ambulatory surgical procedures increase the length of the visit.²² It is not surprising that doing more is associated with a longer visit. However, the findings from our study suggest that longer visits and more physician actions are associated with addressing multiple unrelated problems during the patient encounter, which provides a different perspective on the intensity of the physician’s work.^23-26

Factors that affect the duration of the visit are of interest to those who use physician productivity as a measure for making policy and management decisions. Primary care physician productivity is commonly defined as the number of patients seen per hour.^27,28 Such indicators of productivity would rate a physician who saw many patients in a short time productive, while a physician who provided care to fewer patients but addressed multiple problems would be viewed as less productive. This viewpoint overlooks the cost savings that may result from the reduced number of future visits the patient may require to address these problems, the enhanced quality of care that may be attributable to follow-up of previously identified health concerns, and the enhanced patient satisfaction that may result from the physician’s expanded approach. The current measures of productivity are crude and possibly misleading indicators of the work involved with providing comprehensive primary care to patients. Perhaps health service researchers and policymakers should reconsider the definition of productivity in light of the number of problems addressed or the number of physician actions necessary to address the problems during a patient visit.

Our findings also have implications for evaluating the quality of care provided by family physicians. The current narrowly diseased-focused assessments of quality care are limited because they neglect to take into account the wide range of competing multiple illnesses, prevention, and psychosocial and family context issues confronting family physicians. Quality indicators for primary care should also assess the degree to which family physicians are making the right choices about how to prioritize among the multiple problems that could be addressed during an outpatient visit.