The Relationship between Same-Day Access and Continuity in Primary Care and Emergency Department Visits

We examined how emergency department (ED) visits for potentially preventable, mental health, and other diagnoses were related to same-day access and provider continuity in primary care using administrative data from 71,296 patients in 22 VHA clinics over a three-year period. ED visits were categorized as non-emergent; primary care treatable; preventable; not preventable; or mental health-related. We conducted multi-level regression models adjusted for patient and clinic factors. More same-day access significantly predicted fewer non-emergent and primary care treatable ED visits while continuity was not significantly related to any type of ED visit. Neither measure was related to ED visits for mental health problems.     

Factors predicting patient use of the emergency department: a retrospective cohort study

Background:

Many studies have shown the tendency for people without a regular care provider or primary physician to make greater use of emergency departments. We sought to determine the effects of three aspects of care provided by primary physicians (physician specialty, continuity of care and comprehensiveness of care) on their patients’ use of the emergency department.

Methods:

Using provincial administrative databases, we created a cohort of 367 315 adults aged 18 years and older. Participants were residents of urban areas of Quebec. Affiliation with a primary physician, the specialty of this physician (i.e., family physician v. specialist), continuity of care (as measured using the Usual Provider Continuity index) and comprehensiveness of care (i.e., number of complete annual examinations) were measured among participants (n = 311 701) who had visited a physician three or more times during a two-year baseline period. We used multivariable negative binomial regression to investigate the relationships between measures of care and the number of visits to emergency departments during a 12-month follow-up period.

Results:

Among participants under 65 years of age, emergency department use was higher for those not affiliated than for those affiliated with a family physician (incidence rate ratio [IRR] 1.11, 95% confidence interval [CI] 1.05–1.16) or a specialist (IRR 1.10, 95% CI 1.04–1.17). Among patients aged 65 years and older, having a specialist primary physician, as opposed to a family physician, predicted increased use of the emergency department (IRR 1.13, 95% CI 1.09–1.17). Greater continuity of care with a family physician predicted less use of the emergency department only among participants who made 25 or more visits to a physician during the baseline period. Greater continuity of care with a specialist predicted less use of the emergency department overall, particularly among participants with intermediate numbers of multimorbidities and admissions to hospital. Greater comprehensiveness of care by family physicians predicted less use of the emergency department.

Interpretation:

Efforts to increase the proportion of adults affiliated with a family physician should target older adults, people who visit physicians more frequently and people with multiple comorbidities and admissions to hospital.Reforming primary care in Canada has been stimulated in part by increased crowding of emergency departments and evidence that their use, particularly for nonurgent care, may be related to inadequate primary care in the community.^1,2 Restructuring efforts, such as encouraging family physicians to work in multidisciplinary group practices with 24-hour access, are challenged by a relative shortage of family physicians.³ These issues are of particular importance in Quebec; despite relatively high numbers of family physicians per capita, in comparison with other provinces, residents of Quebec have the lowest rates of affiliation with a family physician and have one of the highest rates of seeing specialists.^4,5 In addition, residents of Quebec have among the highest rates of visits to emergency departments in international comparative studies.^6–8Research is needed into the effect that affiliation with a specialist rather than a family physician has on patients’ use of the emergency department, as is research into the continuity and comprehensiveness of care provided by the primary physician, regardless of specialty.Many studies have shown the tendency for people without a regular care provider to use the emergency department more often than people who have a primary physician.^1,9,10 Greater continuity of care with a primary physician has also been associated with fewer visits to the emergency department, but much of this research is cross-sectional, making causal interpretation difficult.¹¹ Furthermore, the distinction between continuity with a family physician versus a specialist primary physician has not been made, although one American study reported that having a specialist primary physician was associated with increased use of emergency departments.⁹We sought to determine whether certain factors predicted patients’ subsequent use of emergency departments, such as the specialty of their primary physician, the continuity of care with that physician and the comprehensiveness of care provided by that physician. To determine whether certain subgroups of the population may derive greater benefit from a particular type of care, we examined the potentially modifying effects of demographic factors, health status and previous use of health services. We restricted our study to residents of urban areas of Quebec for three reasons: rural residents visit the emergency department for primary care more often than residents of urban areas;¹² most specialist care is provided in urban areas; and primary care services in rural areas are more likely to be provided by salaried physicians, whose information is not available in the billing database.     

Effectiveness of focused structural massage and relaxation massage for chronic low back pain: protocol for a randomized controlled trial

Background

Hypertension affects 29% of the adult U.S. population and is a leading cause of heart disease, stroke, and kidney failure. Despite numerous effective treatments, only 53% of people with hypertension are at goal blood pressure. The chronic care model suggests that blood pressure control can be achieved by improving how patients and physicians address patient self-care.

Methods and design

This paper describes the protocol of a nested 2 × 2 randomized controlled trial to test the separate and combined effects on systolic blood pressure of a behavioral intervention for patients and a quality improvement-type intervention for physicians. Primary care practices were randomly assigned to the physician intervention or to the physician control condition. Physician randomization occurred at the clinic level. The physician intervention included training and performance monitoring. The training comprised 2 internet-based modules detailing both the JNC-7 hypertension guidelines and lifestyle modifications for hypertension. Performance data were collected for 18 months, and feedback was provided to physicians every 3 months. Patient participants in both intervention and control clinics were individually randomized to the patient intervention or to usual care. The patient intervention consisted of a 6-month behavioral intervention conducted by trained interventionists in 20 group sessions, followed by 12 monthly phone contacts by community health advisors. Follow-up measurements were performed at 6 and 18 months. The primary outcome was the mean change in systolic blood pressure at 6 months. Secondary outcomes were diastolic blood pressure and the proportion of patients with adequate blood pressure control at 6 and 18 months.

Discussion

Overall, 8 practices (4 per treatment group), 32 physicians (4 per practice; 16 per treatment group), and 574 patients (289 control and 285 intervention) were enrolled. Baseline characteristics of patients and providers and the challenges faced during study implementation are presented. The HIP interventions may improve blood pressure control and lower cardiovascular disease risk in a primary care practice setting by addressing key components of the chronic care model. The study design allows an assessment of the effectiveness and cost of physician and patient interventions separately, so that health care organizations can make informed decisions about implementation of 1 or both interventions in the context of local resources.

Trial registration

ClinicalTrials.gov identifier NCT00201136     

Information exchange among physicians caring for the same patient in the community

Background

The exchange of information is an integral component of continuity of health care and may limit or prevent costly duplication of tests and treatments. This study determined the probability that patient information from previous visits with other physicians was available for a current physician visit.

Methods

We conducted a multicentre prospective cohort study including patients discharged from the medical or surgical services of 11 community and academic hospitals in Ontario. Patients included in the study saw at least 2 different physicians during the 6 months after discharge. The primary outcome was whether information from a previous visit with another physician was available at the current visit. We determined the availability of previous information using surveys of or interviews with the physicians seen during current visits.

Results

A total of 3250 patients, with a total of 39 469 previous–current visit combinations, met the inclusion criteria. Overall, information about the previous visit was available 22.0% of the time. Information was more likely to be available if the current doctor was a family physician (odds ratio [OR] 1.75, 95% confidence interval [CI] 1.54–1.98) or a physician who had treated the patient before the hospital admission (OR 1.33, 95% CI 1.21–1.46). Conversely, information was less likely to be available if the previous doctor was a family physician (OR 0.38, 95% CI 0.32–0.44) or a physician who had treated the patient before the admission (OR 0.72, 95% CI 0.60–0.86). The strongest predictor of information exchange was the current physician having previously received information about the patient from the previous physician (OR 7.72, 95% CI 6.92–8.63).

Interpretation

Health care information is often not shared among multiple physicians treating the same patient. This situation would be improved if information from family physicians and patients'' regular physicians was more systematically available to other physicians.Continuity of care occurs when patients experience linked care over time and when discrete elements of care are connected.¹ Overall, most studies have shown a benefit of physician continuity, exemplified by lower utilization of emergency and hospital services,^2–5 greater use of preventive interventions,^6–8 improvements in disease-specific symptoms or quality-of-care measures,⁹ and greater patient satisfaction.^10,11Continuity of care has been conceptualized as having 3 primary components:¹ physician continuity, management continuity and information continuity. The root component of information continuity is the availability of data from previous visits by the patient with other physicians. In 3 previous studies, physicians were frequently missing necessary information from visits that patients had made to other physicians.^12–14 However, none of those studies prospectively followed a well-defined cohort of patients.To achieve a better understanding of how information exchange might be improved in the community setting, we sought to identify the patient- and physician-related factors that influence the availability of information from previous visits with other physicians.     

Continuity of primary care and emergency department utilization among elderly people

Background

People aged 65 years or more represent a growing group of emergency department users. We investigated whether characteristics of primary care (accessibility and continuity) are associated with emergency department use by elderly people in both urban and rural areas.

Methods

We conducted a cross-sectional study using information for a random sample of 95 173 people aged 65 years or more drawn from provincial administrative databases in Quebec for 2000 and 2001. We obtained data on the patients'' age, sex, comorbidity, rate of emergency department use (number of days on which a visit was made to an amergency department per 1000 days at risk [i.e., alive and not in hospital] during the 2-year study period), use of hospital and ambulatory physician services, residence (urban v. rural), socioeconomic status, access (physician: population ratio, presence of primary physician) and continuity of primary care.

Results

After adjusting for age, sex and comorbidity, we found that an increased rate of emergency department use was associated with lack of a primary physician (adjusted rate ratio [RR] 1.45, 95% confidence interval [CI] 1.41–1.49) and low or medium (v. high) levels of continuity of care with a primary physician (adjusted RR 1.46, 95% CI 1.44–1.48, and 1.27, 95% CI 1.25–1.29, respectively). Other significant predictors of increased use of emergency department services were residence in a rural area, low socioeconomic status and residence in a region with a higher physician:population ratio. Among the patients who had a primary physician, continuity of care had a stronger protective effect in urban than in rural areas.

Interpretation

Having a primary physician and greater continuity of care with this physician are factors associated with decreased emergency department use by elderly people, particularly those living in urban areas.Canada is reforming its health care system, with primary care as a major focus.¹ The population of Canadians aged 65 years or older is expected to double by 2026² and already accounts for the largest share of total health care expenditures.³ Thus, it is important to evaluate primary care services in this population. Because the emergency department often acts as a safety net for patients receiving inadequate primary care,⁴ emergency department use may be an important indicator of the adequacy of primary care services.The main determinants of emergency department use by elderly people are the severity and the nature of the medical needs of the patient (overall and specific comorbidities).⁵ After adjustment for need, increased access to and continuity of primary care may also be associated with lower emergency department use.⁵ However, most studies that investigated the impact of access and continuity of primary care were carried out in the United States, where the health care system is fundamentally different from Canada''s.^5–8 Furthermore, most of these studies used self- reported measures of access and continuity of primary care.^5,7,9We sought to identify determinants of emergency department use in a population-based sample of elderly people in Quebec, with particular focus on measures of access to and continuity of primary care. Access was defined by 2 measures: (a) presence of a primary physician and (b) physician: population ratio. Relational continuity was defined as the proportion of primary care visits with the primary physician.^10,11 Finally, because primary care services in Quebec are organized differently in urban and rural areas,¹² we also compared the association between emergency department use and continuity of care for urban and rural areas.     

The epidemiology and medical management of low back pain during ambulatory medical care visits in the United States

Background

Low back pain (LBP) is a common symptom.

Methods

Patient visits attributed to LBP in the National Ambulatory Medical Care Survey (NAMCS) during 2003–2004 served as the basis for epidemiological analyses (n = 1539). The subset of patient visits in which LBP was the primary reason for seeking care (primary LBP patient visits) served as the basis for medical management analyses (n = 1042). National population estimates were derived using statistical weighting techniques.

Results

There were 61.7 million (SE, 4.0 million) LBP patient visits and 42.4 million (SE, 3.1 million) primary LBP patient visits. Only 55% of LBP patient visits were provided by primary care physicians. Age, geographic region, chronicity of symptoms, injury, type of physician provider, and physician specialty were associated with LBP patient visits. Age, injury, primary care physician status, type of physician provider, and shared physician care were associated with chronicity of LBP care. Osteopathic physicians were more likely than allopathic physicians to provide medical care during LBP patient visits (odds ratio [OR], 2.61; 95% confidence interval [CI], 1.75–3.92) and chronic LBP patient visits (OR, 4.39; 95% CI, 2.47–7.80). Nonsteroidal anti-inflammatory drugs (NSAIDs) and narcotic analgesics were ordered during 14.2 million (SE, 1.2 million) and 10.5 million (SE, 1.1 million) primary LBP patient visits, respectively. Drugs (OR, 0.29; 95% CI, 0.13–0.62) and, specifically, NSAIDs (OR, 0.40; 95% CI, 0.25–0.64) were ordered less often during chronic LBP patient visits compared with acute LBP patient visits. Overall, osteopathic physicians were less likely than allopathic physicians to order NSAIDs for LBP (OR, 0.43; 95% CI, 0.24–0.76). Almost two million surgical procedures were ordered, scheduled, or performed during primary LBP patient visits.

Conclusion

The percentage of LBP visits provided by primary care physicians in the United States remains suboptimal. Medical management of LBP, particularly chronic LBP, appears to over-utilize surgery relative to more conservative measures such as patient counseling, non-narcotic analgesics, and other drug therapies. Osteopathic physicians are more likely to provide LBP care, and less likely to use NSAIDs during such visits, than their allopathic counterparts. In general, LBP medical management does not appear to be in accord with evidence-based guidelines.     

The Primary Care Network: A New Type of HMO for Private Practice Physicians

A new type of health maintenance organization has been developed to encourage primary care physicians in private practice to become coordinators and financial managers for all medical care. Each patient chooses one internist, family or general physician, or pediatrician and must be referred by that physician for all hospital admissions and care by specialists. The primary care physician authorizes all payments from his own account for care provided to his patients. He shares any deficit or surplus remaining at the end of the year.Hospital admission rates and length of stay are lower than those of Blue Cross, with only one of three dollars paid to hospitals. The plan is providing care to 38,000 persons with 750 participating physicians in Northern California, Washington and Utah.This plan represents an attempt by physicians to control costs without government regulation.     

Setting standards based on patients' views on access and continuity: secondary analysis of data from the general practice assessment survey

ObjectivesTo examine patients'' views on access and continuity in general practice to derive quality standards.DesignSecondary analysis of data from general practice research studies and routine quality assessment activities undertaken by practices and primary care trusts.SettingGeneral practice.ParticipantsGeneral practice patients.ResultsSatisfactory standards of access were next day appointments with general practitioners and a 6-10 minute wait for consultations to begin. A satisfactory level of continuity was seeing the same general practitioner “a lot of the time.” Standards varied with the analytic method used and by sociodemographic group.ConclusionsStandards expected by patients in primary care can be derived from linked report-assessment pairs. Patients may have expectations of access that are in excess of government targets. Patients also have high expectations of continuity of care. It is unclear the degree to which such standards are reliable or valid, how conflicts between access and continuity should be resolved, or how these standards relate to other priorities of patients such as high quality interpersonal care.

What is already known on this topic

Standards are increasingly being set for the provision of health servicesSurveys and consultation exercises before the NHS plan helped set the standard for a maximum waiting time of 48 hours for appointments to see general practitionersThe optimal methods by which patients should be involved in setting standards and the utility of such standards are unclear

What this study adds

Satisfactory standards of access were next day appointments, a 6-10 minute wait for consultations to begin, and seeing the same general practitioner a lot of the timePatients may have expectations for access to primary care in excess of current government targets     

The somatically preoccupied patient in primary care: use of attachment theory to strengthen physician-patient relationships

Background

Individuals with somatic preoccupation constitute a substantial number of primary care patients. Somatically preoccupied patients are challenging to primary care physicians for several reasons including patient complaints consuming a great deal of physician time, expense to diagnose and treat and strain on the physician-patient relationship. This paper examines and discusses how disruptions in early attachment relationships such as often occurs when a female is a victim of child sexual abuse may result in somatic preoccupation in adulthood.

Treatment utilizing attachment theory

Attachment theory provides a useful framework for primary care physicians to conceptualize somatic preoccupation. Utilization and containment techniques grounded in an understanding of attachment dynamics aid the physician in developing a sound physician-patient relationship. Successfully engaging the patient in treatment prevents misunderstandings that frequently derail medical care for somatically preoccupied patients.     

The future of family practice training in California.

Although the number of physicians in California has doubled since 1963, the number of family and general practice physicians has declined. The ratio of office-based primary care physicians to population has also decreased. Graduate medical education is funded largely from patient care revenues, but the low rate of reimbursement for ambulatory care makes training in primary care specialties especially dependent on public support. Medicare, the Veterans Administration, and the University of California provide more than $325 million a year in support of graduate medical education in California. Federal and state grant programs provide $5 million a year for family physician training in the state, but appropriations to these programs have been reduced in real terms. California family practice residencies are disproportionately located at county hospitals, where funding shortfalls make them especially vulnerable to cuts in grant programs. Additional resources will be needed if more family physicians are to be trained.     

Prospective Study of the Quality of Colonoscopies Performed by Primary Care Physicians: The Alberta Primary Care Endoscopy (APC-Endo) Study

Background

The quality of colonoscopies performed by primary care physicians (PCPs) is unknown.

Objective

To determine whether PCP colonoscopists achieve colonoscopy quality benchmarks, and patient satisfaction with having their colonoscopy performed by a primary care physician.

Design

Prospective multi-center, multi-physician observational study. Colonoscopic quality data collection occurred via completion of case report forms and pathological confirmation of lesions. Patient satisfaction was captured by a telephone survey.

Setting

Thirteen rural and suburban hospitals in Alberta, Canada.

Measurements

Proportion of successful cecal intubations, average number of adenomas detected per colonoscopy, proportion of patients with at least one adenoma, and serious adverse event rates; patient satisfaction with their wait time and procedure, as well as willingness to have a repeat colonoscopy performed by their primary care endoscopist.

Results

In the two-month study period, 10 study physicians performed 577 colonoscopies. The overall adjusted proportion of successful cecal intubations was 96.5% (95% CI 94.6–97.8), and all physicians achieved the adjusted cecal intubation target of ≥90%. The average number of ademonas detected per colonoscopy was 0.62 (95% CI 0.5–0.74). 46.4% (95% CI 38.5–54.3) of males and 30.2% (95% CI 22.3–38.2) of females ≥50 years of age having their first colonoscopy, had at least one adenoma. Four serious adverse events occurred (three post polypectomy bleeds and one perforation) and 99.3% of patients were willing to have a repeat colonoscopy performed by their primary care colonoscopist.

Limitations

Two-month study length and non-universal participation by Alberta primary care endoscopists.

Conclusions

Primary care physician colonoscopists can achieve quality benchmarks in colonoscopy. Training additional primary care physicians in endoscopy may improve patient access and decrease endoscopic wait times, especially in rural settings.     

Development of a telemedicine program: a review of 1,000 videoconferencing consultations

Objective To examine the financial and organizational characteristics, demand for services, and satisfaction outcomes of a growing telemedicine program serving both urban or suburban and rural populations. Design Retrospective review of 1,000 consecutive telemedicine consultations in the University of California (UC) Davis Telemedicine Program. Setting Telemedicine videoconferencing units, used to integrate care in the UC Davis Health System among the UC Davis Medical Center and several urban or suburban primary care clinics, rural hospitals, and clinic affiliates. Subjects A total of 657 consecutive patients who consented to a telemedicine consultation. Main outcome measures Demographic information about the patient population, the rural and urban or suburban clinics, the types of specialty consultations, and telemedicine equipment used in the UC Davis Health System. Patient and physician satisfaction were measured on a 5-point Likert scale. Results Patients and primary care physicians reported high levels of satisfaction. Rural clinics requested more and a greater variety of specialist consultations than urban or suburban clinics. Conclusion Although referring physicians and patients indicate a high level of satisfaction with telemedicine services and insurers are negotiating reimbursement policies, additional research must investigate the reasons why some payers, patients, and providers resist participation in these services.     

Clinic-based primary care of frail older patients in California.

We surveyed medical directors of primary care clinics in California to learn how those clinics cared for their frail older patients. Of 143 questionnaires sent, 127 (89%) were returned. A median of 30% of all patient encounters were with persons aged 65 or older, and a median of 20% of older patients were considered frail. A total of 20% of the clinics routinely provided house calls to homebound elderly patients. Of clinics involved in training medical students of physicians (teaching clinics), 70% had at least one physician with an interest in geriatrics, compared with 42% of nonteaching clinics (P less than .005). For frail patients, 40% of the clinics routinely performed functional assessment, while 20% routinely did an interdisciplinary evaluation. Continuing education in geriatrics emerged as a significant independent correlate of both functional assessment and interdisciplinary evaluation. Among the 94 clinics with a standard appointment length for the history and physical examination, only 11 (12%) allotted more than 60 minutes for frail patients. The data suggest that certain geriatric approaches are being incorporated into clinic-based primary care in California but do not provide insight into their content or clinical effects.     

Capitation and enhanced fee-for-service models for primary care reform: a population-based evaluation

Background

Primary care reform in Ontario, Canada, included the initiation of a blended capitation model in 2001–2002 and an enhanced fee-for-service model in 2003. Both models involve patient rostering, incentives for preventive care and requirements for after-hours care. We evaluated practice characteristics and patterns of care under both models.

Methods

Using administrative data, we identified physicians belonging to either the capitation or the enhanced fee-for-service group throughout the period from Sept. 1, 2005, to Aug. 31, 2006, and their enrolled patients. Practices were stratified by location (urban v. rural). We compared the groups in terms of practice characteristics and patterns of care, including comprehensiveness of care, continuity of care, after-hours care, visits to the emergency department and uptake of new patients.

Results

Patients in the capitation and enhanced fee-for-service practices had similar demographic characteristics. Patients in capitation practices had lower morbidity and comorbidity indices. Comprehensiveness and continuity of care were similar between the 2 groups. Compared with patients in enhanced fee-for-service practices, those in capitation practices had less after-hours care (adjusted rate ratio [RR] 0.68, 95% confidence interval [CI] 0.61–0.75) and more visits to emergency departments (adjusted RR 1.20, 95% CI 1.15–1.25). Overall, physicians in the capitation group enrolled fewer new patients than did physicians in the enhanced fee-for-service group (37.0 v. 52.0 per physician); the same was true of new graduates (60.3 v. 72.1 per physician).

Interpretation

Physicians enrolled in the capitation model had different practice characteristics than those in the enhanced fee-for-service model. These characteristics appeared to be pre-existing and not due to enrolment in a new model. Although the capitation model provides an alternative to fee-for-service practice, its characteristics should be the focus of future policy development and research.Primary health care is facing a number of serious challenges internationally, with questions being raised about whether it will even survive in some settings.¹ Fundamental issues include shortages in human resources and maldistribution of physicians; dissatisfaction on the part of providers and patients; gaps between guideline-recommended care and provided care; and a preference of trainees to choose specialty careers. Close to 4 million Canadians do not have a family physician, and more than 2 million report difficulties in accessing routine or ongoing care at any time of day as well as immediate care for minor health problems at any time of day.² Canadians in rural areas face geographic barriers to care, fewer available health care professionals than in urban areas and higher rates of disease.³In response to these challenges, policy-makers in Canada and elsewhere are considering or are implementing interdisciplinary teams, new organizational structures, new governance and reimbursement models, requirements for after-hours care, provision of after-hours advice by telephone, electronic health records and other information technology, and pay-for-performance initiatives. Many of these directions are incorporated in the Medical Home concept in the United States⁴ and in the Quality and Outcomes Framework in the United Kingdom.⁵ Although there is evidence for the effectiveness of some of these initiatives, most have not been rigorously evaluated. Reimbursement models, perhaps the best-studied aspect of primary care reform, seem to influence some aspects of physician behaviour. However, there is a lack of evidence about their ultimate impact on patient outcomes.⁶In Ontario, Canada, a blended capitation model called the Family Health Network was introduced in 2001–2002. An enhanced fee-for-service blended model called the Family Health Group was introduced in 2003. These models rapidly attracted physicians. By 2006, they were the most common models of care in Ontario, exceeding the straight fee-for-service plan.Physicians are free to select one of the models or remain in the straight fee-for-service plan. Many make decisions based on a free revenue analysis that uses their previous billings to project their income under the capitation model. Our evaluation, involving more than 500 physicians and close to half a million patients under the capitation model, is therefore an examination of one of the world’s largest short-term voluntary shifts from fee-for-service to capitation. Our objective was to evaluate practice characteristics and patterns of care under the capitation model, including comprehensiveness, continuity, after-hours care, visits to the emergency department and uptake of unattached patients. We used practices in the enhanced fee-for-service model as a contemporaneous comparison group.     

Bariatric Surgery Patients’ Views of Their Physicians’ Weight‐Related Attitudes and Practices

Objective: A prior study found that nearly 80% of bariatric surgery patients felt that they were treated disrespectfully by members of the medical profession. This study assessed patient‐physician interactions in a group of bariatric surgery patients and in a group of less obese patients who sought weight loss by other means. Research Methods and Procedures: A total of 105 bariatric surgery candidates (mean BMI, 54.8 kg/m²) and 214 applicants to a randomized controlled trial of the effects of behavior modification and sibutramine (mean BMI, 37.8 kg/m²) completed a questionnaire that assessed patient‐physician interactions concerning weight. Results: Only 13% of bariatric surgery patients reported that they were usually or always treated disrespectfully by members of the medical profession, a percentage substantially lower than that found in the previous study. Surprisingly, surgery patients were significantly more satisfied than nonsurgery patients with the care they received for their obesity. Surgery patients also reported significantly more interactions with physicians concerning obesity and weight loss compared with nonsurgery patients. A substantial percentage of both groups, however, reported that their physician did not discuss weight control with them. Discussion: These and other findings suggest that doctor‐patient interactions concerning weight may have improved in the past decade; however, there is still much room for improvement. Increased efforts are needed to help physicians discuss, assess, and potentially treat obesity in primary care practice.     

Management of Obesity in Primary Care

SIMKIN-SILVERMAN, LAUREY R, RENA R WING. Management of obesity in primary care. Obesity is one of the most common presenting chronic medical conditions in primary care, yet it is not adequately treated. Physicians are often reluctant to counsel patients because of their limited training in treating chronic weight problems and negative attitudes toward obese patients. This study evaluated the feasibility of training physicians to provide weight control counseling to their patients. Eleven physicians were randomly assigned to either an obesity-counseling skills training group or to a control group. Physicians in the counseling skills group received training in behavioral and motivational weight control techniques using a five-step patient-centered model; they were also given patient materials for use in their practice. To evaluate pretraining to posttraining changes in physician counseling behavior, independent samples of patients with obesity were surveyed immediately after their visit to the physician's office. Physicians in both the counseling skills training and the control groups discussed weight with 42% to 47% of their patients at baseline. This increased to 89% in physicians who received training, whereas it remained at 42% in control physicians. Scores on a counseling measure also significantly increased from a mean of 2. 7 to 9. 9 in the counseling group, whereas scores in the control group remained low and stable (2. 3 and 1. 9, respectively). The training program was effective in improving the frequency and quality of counseling that physicians delivered to their patients with obesity. Future research is needed to evaluate the effect of physician counseling on the weight and physical activity level of their patients.     

Factors Influencing Patient Pathways for Receipt of Cancer Care at an NCI-Designated Comprehensive Cancer Center

Background

Within the field of oncology, increasing access to high quality care has been identified as a priority to reduce cancer disparities. Previous research reveals that the facilities where patients receive their cancer care have implications for cancer outcomes. However, there is little understanding of how patients decide where to seek cancer care. This study examined the factors that shape patients’ pathways to seek their cancer care at a National Cancer Institute-designated comprehensive cancer center (NCI-CCC), and differences in these factors by race, income and education.

Methods

In-depth interviews and survey questionnaires were administered to a random sample of 124 patients at one NCI-CCC in the Northeast US. In-depth interview data was first analyzed qualitatively to identify themes and patterns in patients’ pathways to receive their cancer care at an NCI-CCC. Logistic Regression was used to examine if these pathways varied by patient race, income, and education.

Results

Two themes emerged: following the recommendation of a physician and following advice from social network members. Quantitative data analysis shows that patient pathways to care at an NCI-CCC varied by education and income. Patients with lower income and education most commonly sought their cancer care at an NCI-CCC due to the recommendation of a physician. Patients with higher income and education most commonly cited referral by a specialist physician or the advice of a social network member. There were no statistically significant differences in pathways to care by race.

Conclusions

Our findings show that most patients relied on physician recommendations or advice from a social network member in deciding to seek their cancer care at an NCI-CCC. Due to the role of physicians in shaping patients’ pathways to the NCI-CCC, initiatives that strengthen partnerships between NCI-CCCs and community physicians who serve underserved communities may improve access to NCI-CCCs.