Family Practice Vol. 20, No. 4, 474-477
© Oxford University Press 2003
International Health Care Research |
Time use during acute and chronic illness visits to a family physician
Department of Research, Olmsted Medical Center,
a Department of Family Medicine,
b Department of Epidemiology and Biostatistics and
c Department of Sociology, Case Western Reserve University,
d Ireland Comprehensive Cancer Center at the University Hospitals of Cleveland and Case Western Reserve University and
e Center for Research in Family Prac-tice and Primary Care, Rochester, MN, USA.
Correspondence to Barbara Yawn, MD MSc, Department of Research, Olmsted Medical Center, 210 Ninth St SE, Rochester, MN 55904, USA; E-mail: yawnx002{at}tc.umn.edu
Yawn B, Goodwin MA, Zyzanski SJ and Stange KC. Time use during acute and chronic illness visits to a family physician. Family Practice 2003; 20: 474–477.
Received 9 August 2002; Revised 3 January 2003; Accepted 28 March 2003.
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Abstract |
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Objective. To identify differences in time use during acute and chronic care visits.
Population. Patients coming to outpatient offices of physician members of a practice-based research network in Ohio.
Measures. Direct observation and coding of physician activities during acute and chronic care visits.
Results. Time use varied by visit type with more time spent on compliance assessment, negotiation, and nutrition advice during chronic care visits. Acute care visits included more time for procedures, physical examination, feedback on test results and health education.
Conclusion. Physicians structure their use of time to fit the differing goals of acute and chronic care visits.
Keywords. Acute care, chronic care, chronic disease management, family medicine, multi-methods research.
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Introduction |
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Most visits to family physicians are for acute problems,1,2 and most practices are set up primarily to react to patients’ acute illness needs. With the growing need for ongoing care of chronic illness, it would be valuable to understand how family physicians use time during visits for chronic medical conditions and whether chronic care visits are structured differently from acute care visits.3,4 Understanding the similarities or differences may be important in improving the management of chronic conditions. Therefore, we used direct observation to compare visit duration and time use during out-patient visits for chronic diseases and acute problems.
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Methods |
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Study design and data collection
This study analysed data from the Direct Observation of Primary Care (DOPC) Study, a cross-sectional study of the content and context of out-patient visits to family physicians, conducted between October 1994 and August 1995. The methods of the DOPC study have been described in detail previously.2 Briefly, participating physicians were members of a practice-based research network whose offices were visited by a team of research nurses on two separate days
4 months apart. In the waiting room, patients were informed that this study was about the content and context of out-patient family practice and were enrolled if they gave verbal informed consent. Trained research nurses directly observed patient visits, administered patient exit questionnaires and performed medical record review of consecutive out-patient visits. Inter-rater reliability among the nurses was excellent, with Kappas ranging from .65 to 1.00 for most observed behaviours.
Measures
The main outcome measure was time use during out-patient visits, as measured by a modified version of the Davis Observation Code (DOC).5 The DOC categorizes every 15 s of the visit into 20 different behavioural categories.
Direct observation was used to measure the length of the visit and the main reason for the visit (acute illness, chronic illness, acute care or wellness care). Only acute illness and chronic illness visits are included in this analysis. Medical record review was used to assess patient age and sex.
Analyses
Potentially confounding patient characteristics were entered into a logistic regression model with nature of the visit (acute versus chronic care) serving as the dependent variable. Subsequently, variables that remained significant in the logistic model plus race were retained as potential confounders in a multivariable analysis of co-variance that compared time use between visits for acute and chronic illness. The Benjamini–Hochberg procedure was used to control for multiple hypothesis testing.6 In addition, a backwards elimination logistic regression analysis was conducted to determine a linear combination of time use variables, controlling for potentially confounding patient characteristics that distinguished between acute and chronic care visits.
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Results |
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Participating family physicians were demographically similar to family physicians nationally,1 but were more likely to be residency trained and female.2 Physicians saw an average of 104 out-patients per week. Eighty-nine percent of eligible patients agreed to participate in the study and were similar to non-participants in terms of sex, race and number of years as a patient, but tended to be slightly older.2 The patient sample has been shown previously to be similar in age, sex and race to out-patients visiting family physicians in the USA.1,2
Patients coming for care of a chronic condition were on average 20 years older, less likely to have more than a high school education, had about twice as many chronic conditions (3.8 versus 1.9) and poorer self-reported health status, and were more likely to be established patients than patients coming for an acute condition. Patient age, sex, being a new versus established patient, number of medications and number of chronic conditions were significant in logistic regression analysis of the two groups and were treated as confounding variables in subsequent analyses of time use.
A significant difference in time use was found between acute and chronic care visits across the 20 time use categories after adjusting for relevant patient characteristics (Wilkes multivariate lambda criterion, F = 6.08, p < 0.001). Table 1
shows the differences in time use at an alpha of 
0.03 using the Benjamin–Hochberg method to adjust for multiple testing.6
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Visits for management of chronic conditions were longer and involved a greater percentage of time spent in history taking, assessing compliance, negotiating, providing or discussing preventive services and providing advice regarding exercise, nutrition and health promotion. In contrast, acute care visits included a higher percentage of time spent on physical examination, procedures, feedback on test results and health education.
Logistic regression analysis significantly differentiated the two types of visits with 76% accuracy (Table 2). Controlling for relevant patient characteristics, nine DOC categories were found to be independent predictors of visit type. For example, each 1% increase in time spent on compliance assessment results in an 8% increase in the odds of a chronic illness visit.
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Compliance assessment, negotiation, nutrition advice, preventive services and exercise advice were most descriptive of chronic care visits, while procedures, physical examination, feedback on evaluation of results and health education best characterized acute care visits.
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Discussion |
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Patient visits to family physicians for acute and chronic illness are different. The observed differences are compatible with the differing goals that physicians, patients and families bring to acute and chronic care.
Many chronic conditions such as diabetes, heart disease and hypertension are affected by the person’s health behaviours, including diet and exercise, and therefore appropriate for greater emphasis during visits.7 Similarly, compliance assessment and negotiation are likely to be more important when the treatment and lifestyle changes are required over long periods of time, compared with the short-term behavioural changes (such as taking a medicine for a week) required to manage acute illness.
An increased emphasis of time spent on physical examination and procedures for acute visits may suggest that more time is required for the assessment of a new undiagnosed illness or an undifferentiated symptom compared with a ‘known’ condition. However, the difference in time given to physical evaluation deserves further exploration. Are physicians and patients assuming they will find few changes in physical findings in patients with chronic illnesses and is this assumption justified due to the frequency of visits or the stability of the patient’s chronic condition? Answers to these questions are important in understanding the impact of continuity and repetitiveness of visits on the content of an individual visit.
Feedback on test results in a chronic condition may be limited and lead immediately to a discussion of therapy compliance or lifestyle modifications. People with long-standing diabetes may need little explanation of a glycosylated haemoglobin result, and the discussion shifts quickly to adherence of home glucose monitoring or diet and exercise advice. Preventive services receive more time during chronic disease visits. While any visit may represent a good time to suggest preventive services,8 patients with chronic illnesses may be more likely to be at a teachable moment.9
Despite the cross-sectional nature of these data, this study shows that visit content varies in logical and systematic ways with the presenting reason for the visit. Understanding these differences can help primary practices reorganize to move away from their current focus on reacting to patients’ acute complaints; developing greater practice capability to engage in the proactive activities needed for chronic illness care10 will become increasingly important as the population ages.
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Acknowledgments |
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The authors are grateful to the participating physicians, practices and their patients, and to Carolyn Hain for her help with preparation of the manuscript. This study was supported by a Family Practice Research Center Grant from the American Academy of Family Physicians and by grants (1RO1CA60862, 2RO1CA60862 and K24 CA81031) from the National Cancer Institute.
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References |
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2 Stange KC, Zyzanski SJ, Flocke SA et al. Illuminating the black box: a description of 4454 patient visits to 138 family physicians. J Fam Pract 1998; 46: 377–389.[ISI][Medline]
3 Yawn BP, Zyzanski SJ, Goodwin MA, Gotler RS, Stange KC. Is diabetes treated as an acute or chronic illness in community family practice? Diabetes Care 2001; 24: 1390–1396.
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8 Woolf SH, Davidson MD, Greenfield S et al. Controlling blood glucoase levels in patients with type 2 diabetes mellitus. An evidence-based policy statement by the American Academy of Family Physicians and American Diabetes Association. J Fam Pract 2000; 49: 453–460.[Medline]
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10 Wagner EH. Chronic disease management: what will it take to improve care for chronic illness. Effect Clin Pract 1998; 1: 1–4.
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