To the Editor:
After reading the abstract of the article by Maly and colleagues1 in the May 1999 issue of the Journal, I had to look more closely at the data. I am in solo rural family practice and pride myself on my communication with my patients. I am always interested in practical ways to improve and facilitate communication.
Although the authors describe the intervention as simple, in my practice it would mean mailing out the progress notes to the patients once they are available from my transcriptionist. This is a costly proposition as far as mailing, copying, and staff time. I hardly consider this simple, but it would still be worth considering if it had a clinically significant impact on my patients.
The data, however, are anything but encouraging. After investing the required amount of time and money (and the energy of my staff), I can expect a 3.7% improvement (from 79.9 to 83.6 on a 0-100 scale). The satisfaction scale was even less impressive: an increase from 31.3 to 31.4 on a scale of 7 to 35. Health status improved from 2.8 to 3.0 on a l to 5 scale (and was lower than the 3.l of the control group).
I believe the conclusions overstate the benefit and certainly do not address the cost-effectiveness of this intervention. Simply stated, this is not a cost-effective use of our staff time and our health care dollars.
—Wayne S. Strouse, MD
Penn Yan, New York
- Maly RC, Bourque LB, Engelhardt RF. A randomized controlled trial of facilitating information-giving to patients with chronic medical conditions. J Fam Pract 1999; 48:356-63.
The preceding letter was referred to Dr Maly who replied as follows:
We appreciate Dr Strouse’s concern about the cost of implementing our intervention for facilitating information-giving to patients with chronic medical conditions. Indeed, primary care physicians are being asked to do more in less time and adding anything else to the process of care may seem quite burdensome. Sharing the same concern, we specifically designed this intervention to be as nonintrusive and easy to incorporate in everyday family practice as possible. As noted in our article, the photocopy of the medical record was of the progress note from the patient’s previous visit only and was handed to patients at the time of their subsequent office visit, so there were no mailing costs. The time required to photocopy what was rarely more than one page from each chart was about 10 to 15 seconds per page, at a photocopy cost of 5 cents per page. In our experience, the additional time and cost incurred in photocopying the progress notes of patients with chronic medical conditions were less than 5 minutes and 50 cents per day per physician’s practice. Obviously, the time and cost required to implement the intervention will vary from practice to practice; however, we believe that they are not likely to be prohibitive in most primary care practices.
Dr Strouse also expressed concern about the magnitude of the intervention’s clinical benefits. We note in our article that improvements were small in the experimental group, approximately 4% to 8% in physical functioning and overall health. However, demonstrating large improvements in broad outcomes, such as overall functioning and health in a population with diverse chronic illnesses, is difficult at best. Resulting effect sizes cannot readily be compared with those traditionally seen in trials of disease-specific drugs or procedures in which discrete physiologic outcomes such as blood pressure are measured. In addition, patients with chronic medical conditions can generally be expected to decline in physical functioning with time as seen in our control patients and as reported in other studies.2,2 We feel that for such a small intervention to have any impact on this population during a relatively short period of time is notable. The maintenance of or even slight improvement in functioning in a population otherwise expected to decline might also have societal significance, especially as the US population ages and chronic conditions become more prevalent in primary care practice. That a large majority of patients receiving the intervention reported that it made visits with their physicians go more smoothly and made them feel better prepared for their visit are also important findings in this era of managed care and declining office visit lengths.
Rose C. Maly, MD, MSPH
UCLA School of Medicine
Los Angeles, California
- Greenfield S, Kaplan SH, Ware JE, Yano EM, Frank HJL. Patients’ participation in medical care: effects on blood sugar control and quality of life in diabetes. J Gen Intern Med 1988; 3:448-57.
- Reuben DB, Frank JC, Hirsch SH, McGuigan KA, Maly RC. A randomized clinical trial of outpatient comprehensive geriatric assessment coupled with an intervention to increase adherence to recommendations. J Am Geriatr Soc 1999; 47:269-76.