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The American Journal of Managed Care October 2016
Cost-Effectiveness of a Statewide Falls Prevention Program in Pennsylvania: Healthy Steps for Older Adults
Steven M. Albert, PhD; Jonathan Raviotta, MPH; Chyongchiou J. Lin, PhD; Offer Edelstein, PhD; and Kenneth J. Smith, MD
Economic Value of Pharmacist-Led Medication Reconciliation for Reducing Medication Errors After Hospital Discharge
Mehdi Najafzadeh, PhD; Jeffrey L. Schnipper, MD, MPH; William H. Shrank, MD, MSHS; Steven Kymes, PhD; Troyen A. Brennan, MD, JD, MPH; and Niteesh K. Choudhry, MD, PhD
Benchmarking Health-Related Quality-of-Life Data From a Clinical Setting
Janel Hanmer, MD, PhD; Rachel Hess, MD, MS; Sarah Sullivan, BS; Lan Yu, PhD; Winifred Teuteberg, MD; Jeffrey Teuteberg, MD; and Dio Kavalieratos, PhD
Patients' Success in Negotiating Out-of-Network Bills
Kelly A. Kyanko, MD, MHS, and Susan H. Busch, PhD
Connected Care: Improving Outcomes for Adults With Serious Mental Illness
James M. Schuster, MD, MBA; Suzanne M. Kinsky, MPH, PhD; Jung Y. Kim, MPH; Jane N. Kogan, PhD; Allison Hamblin, MSPH; Cara Nikolajski, MPH; and John Lovelace, MS
A Call for a Statewide Medication Reconciliation Program
Elisabeth Askin, MD, and David Margolius, MD
Postdischarge Telephone Calls by Hospitalists as a Transitional Care Strategy
Sarah A. Stella, MD; Angela Keniston, MSPH; Maria G. Frank, MD; Dan Heppe, MD; Katarzyna Mastalerz, MD; Jason Lones, BA; David Brody, MD; Richard K. Albert, MD; and Marisha Burden, MD
Mortality Following Hip Fracture in Chinese, Japanese, and Filipina Women
Minal C. Patel, MD; Malini Chandra, MS, MBA; and Joan C. Lo, MD
Estimating the Social Value of G-CSF Therapies in the United States
Jacqueline Vanderpuye-Orgle, PhD; Alison Sexton Ward, PhD; Caroline Huber, MPH; Chelsey Kamson, BS; and Anupam B. Jena, MD, PhD
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Periodic Health Examinations and Missed Opportunities Among Patients Likely Needing Mental Health Care
Ming Tai-Seale, PhD; Laura A. Hatfield, PhD; Caroline J. Wilson, MSc; Cheryl D. Stults, PhD; Thomas G. McGuire, PhD; Lisa C. Diamond, MD; Richard M. Frankel, PhD; Lisa MacLean, MD; Ashley Stone, MPH; and Jennifer Elston Lafata, PhD

Periodic Health Examinations and Missed Opportunities Among Patients Likely Needing Mental Health Care

Ming Tai-Seale, PhD; Laura A. Hatfield, PhD; Caroline J. Wilson, MSc; Cheryl D. Stults, PhD; Thomas G. McGuire, PhD; Lisa C. Diamond, MD; Richard M. Frankel, PhD; Lisa MacLean, MD; Ashley Stone, MPH; and Jennifer Elston Lafata, PhD
Among patients likely needing mental health care, two-thirds had no discussion or perfunctory discussion of mental health during periodic health exams.

Periodic health examinations (PHEs) are the most common reason adults see primary care providers. It is unknown if PHEs serve as a “safe portal” for patients with mental health needs to initiate care. We examined how physician communication styles impact mental health service delivery in PHEs.

Study Design: Retrospective observational study using audio-recordings of 255 PHEs with patients likely to need mental health care.

Methods: Mixed-methods examined the timing of a mental health discussion (MHD), its quality, and the relationship between MHD quality and physician practice styles. MHD quality was measured against evidence-based practices as a 3-level variable (evidence-based, perfunctory, or absent). Physician practice styles were measured by: visit length, verbal dominance, and elicitation of a patient’s agenda. A generalized ordered logit model was used.

Results: Many patients came with mental health concerns, as over 50% of the MHDs occurred in the first 5 minutes of the visit. One-third of the 255 patients had an evidence-based MHD, another third had a perfunctory MHD, and the remaining had no MHD. MHD quality was significantly associated with physician communication styles. Visits with physicians who tend to spend more time with patients, fully elicit patients’ agendas, and let patients talk (instead of being verbally dominant) were more likely to deliver evidence-based MHD.

Conclusions: If done well, PHEs could be a safe portal for patients to seek mental health care, but most PHEs fell short. Improving PHE quality may require reimbursement for longer visits and coaching for physicians to more fully elicit patients’ agendas and to listen more attentively. 

Am J Manag Care. 2016;22(10):e350-e357
Take-Away Points

Periodic health exams (PHEs) could be a “safe portal” for patients with mental health needs to receive care. We found:
  • The quality of mental health discussions varied greatly in 255 audio-recorded PHEs in an 
  • integrated delivery organization: 1 of 3 was evidence-based, 1 of 3 was perfunctory, and 1 of 3 was nonexistent. 
  • Physicians who spend more time with patients, fully elicit patients’ agendas, and let patients talk were more likely to deliver evidence-based mental health care. 
  • Improving care quality may require reimbursement for longer visits, coaching for physicians to fully elicit patients’ agendas, and to listen more attentively. 
  • Routine assessment of mental health status should be reinforced.
The majority of patients with mental health concerns turn to their primary care physicians for help.1,2 Many rely on periodic health examinations (PHEs)—the most common reason for adults to visit physicians.3 Proponents of PHEs argue that, besides increasing the use of preventive services, PHEs bring patients into contact with their primary care physicians, and therefore, provide a route by which patients seek services that they feel uncomfortable disclosing to the scheduling staff. In fact, as many as 1 in 3 patients have undisclosed reasons for requesting a PHE.4 Mental health care needs may be an example of undisclosed reasons that prompt some patients to use the time-honored PHE tradition as a “safe portal” to seek mental health care.

Evidence-based mental health care improves patient outcomes not only through the reduction of mental illness symptoms, but also by improving physical and social functioning.5 Primary care physicians’ communication practices and skills have been documented to influence the quality of mental health service delivery in primary care visits.6 It has been shown that even when patients have an agenda, they commonly do not make it explicit in ambulatory encounters.7-9 Essential communication approaches that can be employed by the physician to ensure effective communication (eg, being open to patients’ agendas10), fully eliciting patients’ concerns and preferences,11 and co-creating the visit agenda with them,12-17 contribute to improving the overall quality of patient–provider communication.

In addition to fully eliciting patients’ agendas for the visit, physicians must give patients enough time to speak. It is not uncommon that some physicians dominate the conversation, in order to control the time used; however, it is necessary to balance the need to manage the conversation with the need to let the patient speak. Verbally dominant physicians disempower patients and impair patient engagement.18 It has been well-documented that patients were less satisfied with their physicians when physicians talked more and when patients perceived their physicians as domineering, and patients were ultimately less likely to sue physicians with low verbal dominance.14,19 The literature is relatively silent on how primary care physicians’ verbal dominance could affect the quality of discussions about mental health during PHEs.

Giving patients time to speak rather than dominating the conversation can affect the length of visits, however. Visit length has long been the subject of research and has been shown to be associated with the delivery of evidence-based preventive health services (both screening and counseling).20,21 It is not known if patients with mental health needs who see primary care providers (PCPs) who tend to provide longer visits with patients may be more likely to receive evidence-based mental health services. Mental health issues are perceived to be difficult and have been well-documented to receive suboptimal attention in ambulatory care settings.6 Furthermore, the provision of mental health screening and counseling during PHEs has received less attention than the delivery of evidence-based biomedical screening and lifestyle counseling during PHEs.20

For PHEs to be valuable to patients with mental health needs, evidence-based mental health discussion is required. Figure 1 illustrates our hypothesis that 3 sets of predisposing physician and patient factors influence the quality of mental health discussion (MHD): evidence-based, perfunctory, or absent. The first group of factors consists of physician practice styles: how much time a physician usually provides in visits, a physician’s openness to the patient’s agenda, and a physician’s verbal dominance. The second set of factors relates to patients’ mental health status and if the patient is in an ongoing episode of care22 for a mental health issue. The third factor relates to a patient’s preparedness for the visit (ie, if a list has been prepared and brought to the visit for discussion with the physician). These tasks have also been shown to increase patient satisfaction and subsequent patient self-management.10,12-15

Using qualitative and quantitative research methods, we investigated whether PHEs offer patients an opportunity to discuss mental health with physicians. We also measured the quality of MHD based on its concordance with evidence-based practices by coding audio recordings and transcripts of PHEs (described later). We further sought to operationalize measures of physician communication styles that could be associated with the delivery of evidence-based MHD and are also potentially malleable.


Study Sample and Data Sources

Patients with mental health needs were drawn from a sample of 484 participants, aged 50 years or older, in a study of preventive health discussions,23 which took place at an integrated health delivery system in Detroit, Michigan, between February 2007 and June 2009. Patients completed a brief telephone survey at recruitment, containing the Patient Health Questionnaire-2 (PHQ-2)24 and sociodemographic characteristics. Furthermore, each patient’s visit was observed and audio recorded by a research assistant. Additional details of the study have been reported elsewhere.21,23,25 The institutional review boards of relevant organizations approved the study. Informed consent of study participants conveyed that the study would examine patient–physician communication about preventive health issues. No specific mention of mental health focus was made.

The sample for the current study consisted of 56 PCPs and 255 patients identified as likely in need of mental health care if they met any of the following criteria: 1) scored ≥2 on the PHQ-2,24 2) filled or were prescribed a psychotropic medication, 3) had a mental health diagnosis (International Classification of Diseases (ICD)-9 codes 290, 293-302, 306-316) in the electronic health record (EHR), or 4) visited a behavioral health provider. The look back period was 12 months before the visit.

Coding of audio recordings of PHEs. Five researchers coded audio recordings and transcripts of the visits to capture topics within 7 major areas: biomedical (eg, high blood pressure), health behaviors (eg, smoking), mental health (eg, depression,), psychosocial (eg, family), physician–patient relationship (eg, physician availability), visit flow management (eg, agenda setting), and other (eg, small talk about weather). Topics were defined as issues that had at least 2 complete exchanges between patient and physician. The time spent on discussing each topic was also recorded for both the patient and the physician. This analytical approach has been described in detail and applied in previous research.26 Studying a visit as a conversational event enabled us to understand the relative time spent on each topic by the patient and the physician, and if and how one person dominated the conversation.26 

Scores from different raters were compared using intra-class correlations for numerical variables and percentage agreement for categorical variables. Intra-class correlations between raters and within the same rater ranged from 0.78 to 0.99.

Variables. The dependent variable was a 3-level variable for the quality of MHD. We defined MHD as any exchange about depression, general anxieties and worries, emotional distress, death, bereavement, grief, mourning, death of others, pain, suffering, concerns, and worries regarding one’s own physical condition, tests, treatments, procedures, or other mood disorders.6 Whether or not the MHD was evidence-based was determined by the degree of concordance with treatment guidelines,27 including if the physician assessed the patient’s mood using any item from the PHQ-9,28 made a mental health diagnosis, prescribed psychotropic medication, made a referral to a mental health specialist, or made a plan for active surveillance of mental health symptoms (Figure 1). Perfunctory discussions (eg, “Any anxiety or depression?”) followed immediately by a nonrelated statement or questions (eg, “Any vaginal spotting or bleeding?”) were coded as non–evidence-based. The value of the outcome measure is 0 for no MHD, 1 for a perfunctory MHD, and 2 for an evidence-based MHD.

Key explanatory variables included both measures of physician practice style and patient characteristics. Physician practice style measures included visit length, eliciting patient agendas, and verbal dominance gathered from their visits with other study patients to form exogenous measures of these constructs to the index visit. Visit length was measured by the face-to-face interaction time in minutes between patients and physicians from other visits. Eliciting patient agenda was defined as the proportion of visits in which the physician attempted to fully identify the patient’s agenda (5 on a scale of 1 to 5)29—there was unanimous agreement among the 5 coders for this variable. Verbal dominance was defined by the ratio of actual talk time by the physician divided by talk time by the patient. To account for physicians’ proclivity to provide evidence-based services, we also included a count of evidence-based preventive services.21 

Patient characteristics were obtained from the EHR, a pre-visit patient survey, and direct office visit observation. Patient health status included whether in an ongoing episode of care (EOC) for mental illness,22 PHQ-2 score, and if the patient had brought a list of issues to discuss.

Analytic Approach

For the quantitative analysis, we specified a generalized ordered logit model with partial proportional odds for the 3-level ordinal dependent variable of evidence-based MHD. Our model constrained the odds ratios to be proportional across these 3 levels for all variables except PHQ-2 score. Tests of the proportional odds assumption indicated it was reasonable for the remaining variables. Three groups of explanatory variables were included in the model, as illustrated in Figure 1. The first group included physician practice style factors, as measured in the other visits to the same physician among the study sample: a) average visit length, b) percent of visits in which they fully elicited the patient’s agenda, and c) verbal dominance.

The second group were patient factors: patient’s mental health needs (ie, self-reported depressive symptoms in the PHQ-2),24 anxiety (ie, self-reported anxiety attack in the previous 4 weeks), and whether the patient was in an ongoing episode of care for mental health.22 The third related to patient activation level (ie, whether the patient brought a list of issues to discuss with the physician). Finally, we controlled for patient demographics (ie, age, sex, race/ethnicity, and education), comorbidity (Charlson Comorbidity Index score30), and the number of evidence-based services delivered in the visit.23 Standard errors were clustered by physician. The statistical analyses were conducted using Stata 14 (STATA, College Station, Texas).

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