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Biomedical subjects

Kurt C Stange

Publications and source records attributed to Kurt C Stange.

At least 37 records · Page 2Linked to original sources
PubMed2002

Direct observation of nutrition counseling in community family practice.

BACKGROUND: Despite the large potential of dietary changes to reduce morbidity and mortality, the frequency, time spent, and factors associated with nutrition counseling in primary care are not well studied. METHODS: In a cross-sectional study of 84 family physician practices in northeast Ohio, nutrition counseling was measured by direct observation on 2 days for all consecutive ambulatory visits. The frequency, time spent, and patient and visit characteristics associated with nutrition counseling were determined. RESULTS: Among 138 family physicians, only 6% included nutrition counseling in the majority (>50%) of patient encounters. Among 3475 consecutive outpatient visits in adults, nutrition counseling occurred in 24% of all patient visits, 17% of visits for acute illnesses, 30% of chronic illness visits, and 41% of well-care visits. The average time spent on nutrition counseling was 55 seconds, ranging from <20 seconds to >6 minutes. Nutrition counseling occurred in 45% of visits for diabetes, 25% of visits for cardiovascular disease, 31% of visits for hypertension, 26% of prenatal visits, and 33% of visits by obese patients (body mass index >30). Nutrition counseling was more likely to occur during visits by patients who were older or had diabetes mellitus, during visits for well care or chronic illness, and during longer visits. CONCLUSION: Despite considerable variability from physician to physician, nutrition counseling occurs in approximately one fourth of all office visits to family physicians. The observed efforts by family physicians to focus nutrition counseling on high-risk patients may increase its impact.

Adult↗
PubMed2002

The anatomy of asthma care visits in community family practice.

BACKGROUND: We know little about the activities that occur during asthma-related visits with primary care physicians. A better understanding of how time is spent during visits for asthma may facilitate the design of programs to enhance asthma disease management. OBJECTIVE: To describe the content of asthma visits made to family physicians. METHODS: Research nurses directly observed consecutive outpatient visits during two separate days in the offices of 138 community family physicians. Time was classified into 20 different behavioral categories using the Davis Observation Code, and compared for visits for asthma, visits for other chronic conditions, and visits for non-asthma-related acute illnesses during 3035 visits by patients of all ages. RESULTS: Visits for asthma shared several characteristics with visits for other chronic conditions but were longer than visits for other chronic illnesses or for acute illness. Asthma visits were distinguished from both acute care and other chronic care visits by a greater percentage of time spent discussing patient compliance, evaluating patient knowledge, and providing smoking assessment and cessation advice. CONCLUSIONS: Visits for asthma are structured differently than acute care visits and specifically address issues important to asthma self-management. Future quality improvement initiatives should recognize, affirm, and enhance many current behaviors by family physicians, while working to expand specific areas of care that still fall short of asthma care guidelines.

Adult↗
PubMed2002

Addressing the unique challenges of inner-city practice: a direct observation study of inner-city, rural, and suburban family practices.

Previous research on geographic variations in health care contains limited information regarding inner-city medical practice compared with suburban and rural settings. Our main objective was to compare patient characteristics and the process of providing medical care among family practices in inner-city, suburban, and rural locations. A cross-sectional multimethod study was conducted emphasizing direct observation of outpatient visits by trained research nurses involving 4,454 consecutive patients presenting for outpatient care to 138 family physicians during 2 days of observation at 84 community family practices in northeast Ohio. Time use during office visits was assessed with the Davis Observation Code; satisfaction was measured with the Medical Outcomes Study nine-item Visit Rating Scale; delivery of preventive services was as recommended by the US Preventive Services Task Force; and patient-reported domains of primary care were assessed with the Components of Primary Care Instrument. Results show that inner-city patients had more chronic medical problems, more emotional problems, more problems evaluated per visit, higher rates of health habit counseling, and longer and more frequent office visits. Rural patients were older, more likely to be established with the same physician, and had higher rates of satisfaction and patient-reported physician knowledge of the patient. Suburban patients were younger, had fewer chronic medical problems, and took fewer medications chronically. Inner-city family physicians in northeast Ohio appear to see a more challenging patient population than their rural and suburban counterparts and have more complex outpatient office visits. These findings have implications for health system organization along with the reimbursement and recruitment of physicians in medically underserved inner-city areas.

Adult↗
PubMed2002

Nurse practitioners and preventive screening in the hospital.

The purpose of this study was to investigate a reminder to discuss cervical cancer screening with hospitalized females. A quasi-experimental design was used to compare the association of a reminder intervention for nurse practitioners with two outcomes: prevalence of cervical cancer screening as documented in patients' charts and patients' self-report of cervical cancer screening 4 months after discharge. Data were collected by chart review and phone survey. The sample consisted of nurse practitioners caring for eligible female patients at a university teaching hospital. Chi-square was used to test all research questions. The rate of documentation of cervical cancer screening increased from 2% to 69% after implementation of the reminder intervention. The reminder intervention did not impact patients actually receiving Pap smears after discharge. The significant increase in documentation of screening associated with the use of the single reminder in the patients' charts support the use of this low-cost intervention.

Adolescent↗
PubMed2002

A comparison of ambulatory services for patients with managed care and fee-for-service insurance.

OBJECTIVES: To determine whether family physicians provide different ambulatory care to patients with health insurance from managed care organization (MCO) versus fee-for-service (FFS) plans. STUDY DESIGN: Multimethod cross-sectional observational study. PATIENTS AND METHODS: A total of 4454 patients made office visits to 138 family physicians in northeastern Ohio. Direct observation with the Davis Observation Code and a structured checklist were used to assess the process of care. Patient satisfaction was measured with the Medical Outcomes Study 9-Item Visit Rating Form. RESULTS: Among 1588 patients with MCO insurance and 876 with FFS insurance, no differences were noted in the number of visits per year, length of visits, percentage of visits for well care, or the percentage of visits in which medicines were prescribed in analyses controlling for patient mix. Visits by patients with MCO insurance were more likely to involve referrals to another physician than visits by patients with FFS insurance. Patient satisfaction and time use during visits were comparable for the 2 groups. CONCLUSIONS: Managed care insurance appears to increase involvement of the primary care provider in the referral process. However, in a healthcare market with moderate managed care penetration in which the same physicians see patients with different types of insurance, the process of care is affected little by type of insurance coverage.

Adult↗
PubMed2002

Does patient educational level affect office visits to family physicians?

Significant disparities in health care based on patient socioeconomic status have been documented. The extent to which physician behavior accounts for these differences is not known. We examined the impact of patient socioeconomic status, measured by years of education, on physician behavior assessed by direct observation of office visits, chart audits, and patient reports among 138 family physicians in 84 practices. Outcomes included time use measured with the Davis Observation Code, delivery of preventive services recommended by the US Preventive Services Task Force, satisfaction assessed with the MOS 9-item Visit Rating Scale, and delivery of attributes of primary care measured by the Components of Primary Care Index. After controlling for patient characteristics among 2538 visits by adult patients who returned questionnaires, a high school education or less was associated with slightly greater proportion of time spent on physical examination and providing nutrition counseling, and less time on patient questions, assessing patient health knowledge, negotiation, and exercise counseling. This indicates that physicians adopt a more directive style with less educated patients. Screening tests were provided at lower rates among less educated patients, but there were no differences in rates of health habit counseling or immunization services delivered and no differences in delivery of patient-reported components of primary care. Less educated patients had similar overall visit satisfaction, but were slightly less likely to have their expectations met. These show that patients' education has relatively small, but potentially important, effects on the outpatient delivery of primary care.

Cross-Sectional Studies↗
PubMedDate not supplied

Physician and staff turnover in community primary care practice.

The effect of a rapidly changing healthcare system on personnel turnover in community family practices has not been analyzed. We describe physician and staff turnover and examine its association with practice characteristics and patient outcomes. A cross-sectional evaluation of length of employment of 150 physicians and 762 staff in 77 community family practices in northeast Ohio was conducted. Research nurses collected data using practice genograms, key informant interviews, staff lists, practice environment checklists, medical record reviews, and patient questionnaires. The association of physician and staff turnover with practice characteristics, patient satisfaction, and preventive service data was tested. During a 2-year period, practices averaged a 53% turnover rate of staff. The mean length of duration of work at the current practice location was 9.1 years for physicians and 4.1 years for staff. Longevity varied by position, with a mean of 3.4 years for business employees, 4.0 years for clinical employees, and 7.8 years for office managers. Network-affiliated practices experienced higher turnover than did independent practices. Physician longevity was associated with a practice focus on managing chronic illness, keeping on schedule, and responding to insurers' requests. No association was found between turnover and patient satisfaction or preventive service delivery rates. Personnel turnover is pervasive in community primary care practices and is associated with employee role, practice network affiliation, and practice focus. The potentially disruptive effect of personnel turnover on practice functioning, finances, and longitudinal relationships with patients deserves further study despite the reassuring lack of association with patient satisfaction and preventive service delivery rates.

Humans↗
PubMedDate not supplied

The Future of Family Medicine: a collaborative project of the family medicine community.

BACKGROUND: Recognizing fundamental flaws in the fragmented US health care systems and the potential of an integrative, generalist approach, the leadership of 7 national family medicine organizations initiated the Future of Family Medicine (FFM) project in 2002. The goal of the project was to develop a strategy to transform and renew the discipline of family medicine to meet the needs of patients in a changing health care environment. METHODS: A national research study was conducted by independent research firms. Interviews and focus groups identified key issues for diverse constituencies, including patients, payers, residents, students, family physicians, and other clinicians. Subsequently, interviews were conducted with nationally representative samples of 9 key constituencies. Based in part on these data, 5 task forces addressed key issues to meet the project goal. A Project Leadership Committee synthesized the task force reports into the report presented here. RESULTS: The project identified core values, a New Model of practice, and a process for development, research, education, partnership, and change with great potential to transform the ability of family medicine to improve the health and health care of the nation. The proposed New Model of practice has the following characteristics: a patient-centered team approach; elimination of barriers to access; advanced information systems, including an electronic health record; redesigned, more functional offices; a focus on quality and outcomes; and enhanced practice finance. A unified communications strategy will be developed to promote the New Model of family medicine to multiple audiences. The study concluded that the discipline needs to oversee the training of family physicians who are committed to excellence, steeped in the core values of the discipline, competent to provide family medicine's basket of services within the New Model, and capable of adapting to varying patient needs and changing care technologies. Family medicine education must continue to include training in maternity care, the care of hospitalized patients, community and population health, and culturally effective and proficient care. A comprehensive lifelong learning program for each family physician will support continuous personal, professional, and clinical practice assessment and improvement. Ultimately, systemwide changes will be needed to ensure high-quality health care for all Americans. Such changes include taking steps to ensure that every American has a personal medical home, promoting the use and reporting of quality measures to improve performance and service, advocating that every American have health care coverage for basic services and protection against extraordinary health care costs, advancing research that supports the clinical decision making of family physicians and other primary care clinicians, and developing reimbursement models to sustain family medicine and primary care practices. CONCLUSIONS: The leadership of US family medicine organizations is committed to a transformative process. In partnership with others, this process has the potential to integrate health care to improve the health of all Americans.

Ambulatory Care Information Systems↗
PubMedDate not supplied

New knowledge for and about primary care: a view through the looking glass of the Annals of Family Medicine.

PURPOSE: At this second anniversary of the Annals of Family Medicine, we sought to characterize primary care research and to identify opportunities for new directions by analyzing the content of the first and second volumes of the Annals. METHODS: Using an a priori classification scheme, 2 editors independently categorized each research article and essay published in 2003 and 2004, excluding supplements. We categorized the domain of knowledge, methods, topical content, whether articles represented core values of primary care, and looked for articles that studied health/illness/symptoms from a uniquely primary care experience. We reconciled differences by discussion. RESULTS: Among 110 articles, knowledge domains reflected the 4 quadrants of the clinician (n = 6), patient, family, or community (10), health care system (32), disease (22), or the interface (39) between these quadrants. The most frequent methods were cross-sectional studies (23), cohorts (15), randomized clinical trials (13), qualitative interviews (11), analyses of secondary data (11), systematic reviews (11), methods/theory development (10), self-reflections (8), and mixed methods (5). The most common topical areas were chronic disease and prevention. Core primary care values were represented in 75% of articles. Only 2 articles represented an integrative illness/healing perspective. CONCLUSIONS: Despite contemporary forces driving a reductionistic approach, primary care research, as reflected by articles published in the Annals of Family Medicine, addresses the domains of knowledge that contribute to comprehensive, relationship-centered health care. More work is needed to understand the nature of health and illness in whole people and ways to integrate diverse knowledge, methods and fragmented health care.

Health Knowledge, Attitudes, Practice↗
PubMedDate not supplied

Delivery of clinical preventive services in family medicine offices.

BACKGROUND: This study aimed to elucidate how clinical preventive services are delivered in family practices and how this information might inform improvement efforts. METHODS: We used a comparative case study design to observe clinical preventive service delivery in 18 purposefully selected Midwestern family medicine offices from 1997 to 1999. Medical records, observation of outpatient encounters, and patient exit cards were used to calculate practice-level rates of delivery of clinical preventive services. Field notes from direct observation of clinical encounters and prolonged observation of the practice and transcripts from in-depth interviews of practice staff and physicians were systematically examined to identify approaches to delivering clinical preventive services recommended by the US Preventive Services Task Force. RESULTS: Practices developed individualized approaches for delivering clinical preventive services, with no one approach being successful across practices. Clinicians acknowledged a 3-fold mission of providing acute care, managing chronic problems, and prevention, but only some made prevention a priority. The clinical encounter was a central focus for preventive service delivery in all practices. Preventive services delivery rates often appeared to be influenced by competing demands within the clinical encounter (including between different preventive services), having a physician champion who prioritized prevention, and economic concerns. CONCLUSIONS: Practice quality improvement efforts that assume there is an optimal approach for delivering clinical preventive services fail to account for practices' propensity to optimize care processes to meet local contexts. Interventions to enhance clinical preventive service delivery should be tailored to meet the local needs of practices and their patient populations.

Family Practice↗
PubMedDate not supplied

Prescription for health: changing primary care practice to foster healthy behaviors.

PURPOSE: The leading causes of premature death in the United States are linked to 4 behaviors: smoking, unhealthy diet, physical inactivity, and risky alcohol use. We report lessons from 17 exploratory projects funded under Prescription for Health that tested the feasibility of innovative behavior change strategies for at least 2 of these behaviors in primary care practices. METHODS: Seventeen practice-based research networks (PBRNs) implemented and evaluated tools, cues, and techniques in 120 family medicine, internal medicine, pediatric, and nursing practices across an ethnically diverse sample of adults, children, and adolescents in rural and urban settings. We reviewed progress reports and notes from site visits and 3 meetings to generate overarching lessons. RESULTS: PBRNs successfully implemented their projects in diverse practices despite reported logistical challenges and practice constraints. The networks showed that distributing the effort across the care team and throughout the practice and community is possible. Although each behavior required specific attention, each did not require its own separate staff and system. Three models emerged as helpful guides for the comprehensive redesign of health behavior counseling, but they require adaptation for use in real-world primary care settings. Traditional methods of collaboration yielded mixed results, making obvious a need for dedicated collaboration funds and a better framework to identify and align high-yield opportunities. CONCLUSIONS: These projects confirm the feasibility of health behavior counseling in primary care practice. They also highlight the need for substantive practice redesign, and the value of models and frameworks to guide redesign and collaborative efforts.

Health Behavior↗