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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.
To provide some contextual information on how visits between physicians at different levels of verbal dominance might evolve differently, we selected a few visits with high versus low verbally dominant physicians seeing patients with similar PHQ-2 scores to examine the timing and quality of mental health discussion. We mapped the topics, sequentially, as they took place during the visit.


Visit, Patient, and Physician Characteristics

Table 1 summarizes the characteristics of the study sample: 255 patients likely in need of mental health care saw 53 physicians practicing in about 2 dozen primary care clinics. The majority of patients were white (66%) and female (63%), with an average age of 60. About 9% of patients reported having an anxiety attack in the 4 weeks prior to study recruitment, the average PHQ-2 score was 1.1 [standard deviation (SD) = 1.5], and 37% were in an ongoing episode of care for a mental health condition. Their Charlson Comorbidity Index scores averaged 0.8 (SD = 1.4); 11% of patients brought a written list. These did not vary by MHD levels.

The median visit length was 26 minutes (SD = 10.3). A third of visits (33%) contained no MHD, 33% had an evidence-based MHD, and 34% had a perfunctory MHD.

Among the physician factors, the average length of other nonindex visits was 27 minutes (SD = 8) and rose with the level of MHD, from absent to perfunctory to evidence-based: 25 (SD = 6), 28 (SD = 9), and 29 (SD = 8), respectively. The average percent of visits in which the physician fully elicited the patient’s agenda in other nonindex visits was 25% and increased with the level of MHD, from absent to perfunctory to evidence-based: 19, 27, and 29, respectively. The average physician verbal dominance in other visits was 3.2 (SD = 2.2) and declined in visits with absent, perfunctory, and evidence-based MHD: 3.8 (SD = 2.8), 3.2 (SD = 2.1), and 2.6 (SD = 1.2), respectively. Finally, the average number of evidence-based services delivered was 2.9 (SD = 1.5) and increased with the level of MHD from absent to perfunctory to evidence-based: 2.7 (SD = 1.4), 2.8 (SD = 1.4), and 3.2 (SD = 1.6), respectively.

Mental Health as a Reason for Some Patients to Schedule a PHE

Over 50% of MHDs occurred within the first 5 minutes of visit initiation (median = 4.9; SD = 9.1). Ninety percent of them occurred within the first 19 minutes of the visit, which is 7 minutes fewer than the median visit length. The median time of MHD initiation was 6.3 minutes for perfunctory versus 3.3 minutes for evidence-based discussions (P <.05). Thus, evidence-based MHDs occurred 3 minutes earlier in the visit than perfunctory MHDs.

In addition to MHDs occurring in the first few minutes of the visit, the nature of the conversation also suggested that mental health might have been a reason that some patients scheduled a visit. For example, one patient said that she “might need kind of an antidepressant” 54 seconds into her visit. She then broke down in tears and told the doctor that her sister was recently diagnosed with lung cancer. Another patient started to cry before the physician closed the exam room door, saying, “And I knew as soon as I saw you I would start to cry.” She stated that she was stressed out at work, “wake[s] up in the middle of the night, worry, worry, worry,” and then said, at 1 minute 24 seconds, “And I want a happy pill. Is there such a thing?”

Factors Associated With the Quality of Mental Health Discussion

Figure 2 shows results from the proportional logistic model for the 3 levels of MHD. The model cumulates over adjacent levels of the 3-level MHD quality outcome variable to form odds ratios. Our model assumes the odds ratios are the same for evidence-based MHD versus the combination of perfunctory MHD and no MHD, as they are for the combination of evidence-based MHD and perfunctory MHD versus no MHD. For ease of exposition, we state that each odds ratio is the proportional change in the odds of a “higher-quality visit” for each unit increase in the explanatory variable (scaled to SDs for the continuous variables: age, Charlson Comorbidity Index score, physician verbal dominance, visit length, and PHQ-2 score). For every SD increase in length of the physician’s other visits (SD = 7.8), the odds of having a higher-quality visit was 1.4 times greater. Similarly, the odds of having a higher-quality visit were 2.7 times higher among physicians who fully identified their patients' agenda (5 on the original 1 to 5 scale) compared with any other level of agenda setting. Increased physician verbal dominance is associated with lower odds of a higher-quality visit. Female patients were twice as likely as males to receive a higher-quality visit. White patients’ odds were 1.8 times higher than nonwhites’ of receiving higher-quality visit. Higher PHQ-2 scores (SD = 1.5) were associated with 1.8 times higher odds of evidence-based MHD compared with the combined perfunctory and no MHD, but not with increased odds of having any MHD versus no MHD.

Mental Health Discussion and Physician Verbal Dominance

Below we describe 2 mental health discussions (one perfunctory, the other evidence-based) that exemplified physicians with different levels of verbal dominance.

Physician with high verbal dominance. Patient 1’s PHQ-2 score was 4, indicating a high likelihood of depression. The patient had no other mental health diagnoses besides hyperkinetic syndrome in her childhood, recorded in the EHR. Physician A’s verbal dominance score for other sample visits was 9.7 (almost 3 SDs above the mean), indicating a tendency for Physician A to have a more dominant communication style relative to other physicians in the study. (There were only 5 physicians whose verbal dominance score was 10 or higher.)

Figure 3 illustrates the conversation flow between Physician A and Patient 1. Each color represents the talk time spent by the participant for each instance: dark blue for patient and light blue for physician. The longest biomedical exchange contained topics encompassing shortness of breath, high blood pressure, and bone density. Patient 1 talked for 56 seconds during the 10-minute, 13 second exchange. For the mental health topic, the exchange between Physician A and Patient 1 was as follows: Physician A: “... and you were followed back in behavioral services, and you still see [name of psychiatrist]?” Patient 1: “Yes.” Physician A: “Okay. Things are going well there?” Patient 1: “Yes. It’s going okay.”  When Physician A asked the leading questions, “Things are going well there?” Patient 1 answered “It’s going okay.” “Okay” is a qualified statement and is not the same as “great,” ”excellent,” or “fine.” Conversation analysts have noted that “Okay” in response to an opening exchange typically operates as an invitation for further discussion.31 However, Physician A did not explore why Patient 1’s response was only “Okay.” Therefore, the discussion was considered perfunctory.

Physician with low verbal dominance. The verbal dominance score of Physician B from other visits was 1.24 (ie, she spoke only somewhat more than her patients in the other visits in this sample). Patient 2’s PHQ-2 was 6, the highest score for PHQ-2. Physician B explored empathic opportunities,32 asked 8 of the 9 PHQ-9 questions, diagnosed depression, prescribed Effexor, and made a referral for psychotherapy. Part of the discussion is as follows: Physician B: “And you know what? Sometimes as crappy as it feels that you’re going through all these crappy feelings—” Patient 2: “Oh, this is awful.” Physician B: “—you could kind of look at it as a gift. Like okay, now’s your time. You have to do it. You have to deal with these things, you know?” Patient 2: “Right. Right.”


Among patients likely needing mental health care, only one-third had evidence-based mental health discussions. Another third of the visits had perfunctory MHDs, leaving the remaining third of patients without any MHD. The significant effects of physician practice styles on presence and quality of an MHD deserve our attention.

Patients seeing physicians who spent more time with their other patients were more likely to have a higher-quality MHD. This finding echoes the observation that “slow medicine” can be more appropriate for serving patients with chronic conditions.33 It is also consistent with previous research that suggests visits in which physicians who provided appropriate counseling or screening took 2.6 to 4.2 minutes longer than visits in which patients did not receive these services.20 An analysis of 190 video-recorded visits in Europe also suggests that when both physician and patient considered psychosocial problems to be important, consultations lasted longer than those about biomedical problems only.34 Nevertheless, some physicians are reluctant to deal with patients’ complex agendas because they are “overly time consuming.”9

As our population ages, the number of patients with chronic conditions is rising rapidly. Visit lengths should not be arbitrarily set without much tailoring to patients’ individual needs.35 Offering longer visits for patients with mental health needs would require either smaller caseloads or more staff to do pre-visit and postvisit services, or less frequent visits. Above all, evidence-based practices, such as using standardized mental health assessment tools and engaging patients in shared decision making, ought to be routine and not left to chance.

Efforts to improve quality of care should incorporate evidence beyond the simple association between visit length and quality of care. We need to examine potentially malleable physician communication behaviors and focus on their impact on quality of care. One of those behaviors is verbal dominance. Although it may be more expeditious to actively direct the conversation and maintain control, verbal dominance disempowers patients. Physicians who fear that addressing mental health issues is too time-consuming spend insufficient time addressing their patients’ mental health.36-38 Other physicians find that asking patients about their suffering and listening to their answers is gratifying and takes little additional time.39 A study of patient clues and physician responses in primary care and surgery found that 76% of patient-initiated clues were emotional in nature, and visits in which physicians missed the opportunity to adequately address patients’ emotional clues were actually longer than visits with a positive response.40 Furthermore, treating mental illnesses can improve the course of comorbid medical illnesses.41 The deficiencies in medical education regarding how to provide evidence-based mental health care should be addressed.

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