Evaluating Care Delivery

The American Journal of Managed Care, September 2004, Volume 10, Issue 9 Abstract

Ambulatory Care Visits: Squeezing 22 Minutes Into A 19-Minute Visit?

Sung SH, Price M, Tallman K, et al.


John Hsu, MD, MBA, MSCE, Kaiser Permanente Division of Research, 2000 Broadway, Oakland CA 94612. E-mail: jth@dor.kaiser.org.

Background: Balancing patient and provider demands for time during an ambulatory visit represents a significant clinical and economic challenge.

Objective: To examine actual visit times, patient satisfaction with time spent with the physician, and time perceptions of patients and physicians.

Methods: We collected video and post-visit questionnaire data from a convenience sample of patients and primary care physicians. We examined the time perceptions of how long physicians were in the exam room, stratified by whether patients felt they had adequate time with the physician. Using a mixed linear model, we evaluated differences in time estimates between the patient, physician, and a researcher watching the video.


Results: There were 192 patient-subjects, who tended to be female (61%) and non-white (59%), and had a mean age of 63 years. The 61 physician-subjects were predominantly male (59%), and had &#8805;10 years experience in the health system. Overall, 84% of patients strongly felt that their physician spent enough time with them during their visit. On average, these patients estimated physicians spent 22 minutes in the exam room, while physicians estimated 19 minutes; and the actual mean time was 19 minutes. In visits where patients were less satisfied, on average the patients estimated physicians spent 19 minutes in the exam-room, while physicians estimated 20 minutes; and the actual mean time was 18 minutes. After adjusting for age, gender, and clustering by physician, highly satisfied patients reported significantly more time spent with the physician on average, compared with physicians' estimates or with actual measured time (difference = 2.6 minutes and 2.4 minutes, respectively [ < .01]). There were no statistically significant differences in actual visit times by patient satisfaction or between physician estimates and actual times.

Conclusions: Patients who are highly satisfied perceive spending significantly more time with the physician than actually occurred. In contrast, less-satisfied patients' time estimates did not differ from actual times, nor did physician time estimates. Similarly, there were no detectable differences in actual time between visits with varying patient satisfaction. These preliminary results suggest that there may be methods to help patients feel that they have spent an adequate amount of time with their physician within the current visit-times.

Case-Control Study of Arthritis Health Care Utilization

Diseker R, Tolsma D


Robby Diseker, MPH, Kaiser Permanente Georgia, 3495 Piedmont Rd. NE, Bldg 9, Atlanta, GA 30305. E-mail: robert.diseker@kp.org.

Background: Arthritis and other rheumatic conditions have a major impact on the health of nearly 45 million persons in the United States and are the leading cause of disability. While the Centers for Disease Control (CDC) and other organizations have measured arthritis prevalence using self-reported data from health interview surveys, there is increased interest in surveillance systems that can take advantage of administrative and clinical data available in managed care administrative databases. Kaiser Permanente Georgia (KPGA), in association with the CDC and Georgia Department of Public Health, previously conducted and published an arthritis surveillance study.

Objective: To conduct additional analysis that provides an understanding of the additional burden of arthritis upon healthcare utilization.

Methods: The service area of KPGA is the 20-county Atlanta Metropolitan area, and covers approximately 282 000 members, or approximately 7% of the population in this area. With respect to age, race/ethnicity and socioeconomic status, membership is representative of the area population and it has been shown that the arthritis prevalence is similar to that of the United States. Using data from the previous analysis, we compared 1-year (1999) of healthcare utilization in 77 000 arthritis patients to non-arthritic control subjects matched on age, sex, number of months enrolled during 1999, and home healthcare facility. The difference in utilization between these 2 groups estimated the utilization attributable to arthritis. Healthcare utilization was stratified by primary and specialty care outpatient visits, inpatient, and emergency department visits.

Results: Arthritic persons averaged 3 more healthcare visits per year than non-arthritic persons with the heaviest burden falling into primary care (2 more) and specialty care (1 more) visits. Arthritic persons visited the emergency room twice as frequently as non-arthritic persons and had 50% more hospitalizations and hospital days.

Conclusions: Arthritis related diseases contribute a considerable burden to the healthcare delivery system. Effective case management and arthritis self-management programs could help reduce utilization of healthcare services.

Effects of Group Visits for Hmong Patients with Type 2 Diabetes Mellitus: Quantitative and Qualitative Analyses

Culhane-Pera KA, Crain AL, Her B, Xiong T


Kathie Culhane-Pera, MD, MA, Health Partners, 475 Holly Avenue, St Paul, MN 55102. E-mail: kathiecp@yahoo.com.

Background: Hmong refugees with type 2 diabetes mellitus (DM2) have poor glycemic control. Group visits have improved glycemic control in mainstream patients, and could be helpful for Hmong patients.

Objective: To evaluate the effect of group visits for Hmong patients with DM2 in improving glycemic control.


Methods: Evaluation of group visit intervention at a community clinic network involved 39 patients (64% of known Hmong adults with DM2). Groups were conducted at 3 clinics and met monthly for three months, then quarterly for 1 year. Matched -tests compared pre- and postintervention biological variables (hemoglobin A1C (A1C), blood pressure (BP), low-density lipoprotein (LDL), body-mass index, micro-albuminuria), Hmong Hopkins Symptom Checklist 25 (HHSC-25), and self-reported diet and exercise. Qualitative analyses of hour-long group visit discussions were done by 2 investigators on N*6 using standard qualitative data analysis methods and were reviewed by third person.





Results: Subjects had mean age of 57 years, mean duration of diabetes of 5.1 years, and 64% were women. Subjects attended a median of 4 group sessions. Mean baseline A1C was 9.5%, BP 133/78, and LDL 128. Pre- and postbiological variables did not change. HHSC-25 anxiety and total mental health scores improved ( < .01 and < .05, respectively). Self-reported diet and exercise worsened ( < .05). Mean number of prescribed medicines increased from 3.2 to 4.6 ( < .001). Care guidelines were followed (82% flu shots, 87% feet exam, and 87% eye exam.) People understood diabetes as a result of their refugee experience, from loss of country, culture, and lifestyle. Diabetes was blamed on change in diet (increase in amount, new foods, and chemicals), lack of sweating (to get rid of salt, sugar, and chemicals from food), and emotions (stress in family relations, and depression). Adjustment to diabetes was difficult, due to challenges in adjusting to life in the Unite States, fears of complications and medicines, anger at disease and family, and exasperation with limited results from efforts. Peer support was expressed in multiple ways.

Conclusion: The intervention was associated with intensified treatment of diabetes and related conditions, and led to improved mental health, but did not improve glycemic control. Group visits may have had positive influence on emotional aspect of dealing with diabetes. One year may be insufficient time to illustrate improved glycemic control.

Improving Laboratory Monitoring at Initiation of High Risk Drug Therapy: A Randomized Practical Clinical Trial

Raebel MA, Magid DJ, Lyons EE, Miller C, Chester EA, Bodily MA


Marsha A. Raebel, PharmD, Kaiser Permanente Colorado, PO Box 378066, Denver, CO 80237-8066. E-mail: marsha.a.raebel@kp.org.

Background: Monitoring laboratory parameters is indicated before and during therapy for drugs with adverse events related to lack of monitoring, but medical literature suggests that monitoring of these drugs is performed less often than recommended.

Objective: To test whether a computerized tool alerting pharmacists to missing laboratory orders would be effective in increasing the proportion of patients receiving laboratory monitoring at initiation of high-risk drug therapy.

Methods: We conducted a controlled trial in which we randomized the 375 000 members of Kaiser Permanente of Colorado to either have prescribing and laboratory test information sent electronically to the Kaiser Permanente of Colorado Clinical Pharmacy Call Center (CPCC) (intervention) or to receive usual care (control). For 18 high-risk drugs, CPCC pharmacists received reports of drug dispensings plus drug-specific laboratory tests for which either the test was not a) ordered or b) had not been completed by the patient. The CPCC pharmacists contacted patients to remind them about laboratory tests their providers had ordered and/or they ordered the appropriate test(s). Laboratory results ordered by the CPCC pharmacists were returned to them for evaluation. A guideline for managing abnormal laboratory results was developed and approved. Standardized scripts were used to notify patients' providers about recommended actions.


Results: Results from the first 6 months document 1854 (76.7%) drug dispensings with laboratory monitoring in the intervention group compared to 1630 (67.8%) dispensings with laboratory monitoring in the control group ( < .01). Abnormal results were documented in 10% of laboratory tests performed in the intervention group. Allopurinol (15.7%) and amiodarone (12.8%) had the highest percentages of abnormal patient test results.

Conclusions: This study demonstrates that coupling research, information systems, and physicians' and pharmacists' clinical knowledge and skills is effective in improving laboratory monitoring of high-risk drugs.

The Near Absence of Osteoporosis Treatment in Older Men with Fractures

Feldstein AC, Nichols G, Orwoll E, et al.


Adrienne C. Feldstein, MD, MS, Kaiser Permanente Center for Health Research, 3800 N. Interstate Ave., Portland OR 97227-1110. E-mail: adrianne.c.feldstein@kpchr.org.

Background: The burden of osteoporotic fractures in older men is significant, and treatment rates for secondary prevention are low.

Objectives: To 1) characterize older men with fractures associated with osteoporosis; 2) determine if treatment rates for osteoporosis are improving; and 3) identify patient, healthcare benefit and utilization, and clinician characteristics that are significantly associated with treatment.

Methods Design: Retrospective cohort study using multiple logistic regression to evaluate pre-fracture factors for their association with osteoporosis treatment in the 6-month post-fracture period.

Setting: A non-profit health maintenance organization in the United States.

Participants: Men aged 65 or older with any new fracture associated with osteoporosis between January 1, 1998, and June 30, 2001 (n =1171).

Main Outcome Measure: Pharmacologic treatment for osteoporosis in the 6 months after the index fracture.

Results: Average age was 76.7 years; 3.3% had a diagnosis of osteoporosis and 15.2% a diagnosis or medication associated with secondary osteoporosis. Only 7.1% of the study population received a medication for osteoporosis following the index fracture, and treatment rates did not improve over time. Seventy-two percent of the treated group had a vertebral fracture. In the multivariate model, a higher value on the Charlson Comorbidity Index (OR 1.26, 95% CI 1.05-1.51), having an osteoporosis diagnosis (OR 8.11, 95% CI 3.08-21.3), chronic steroid use (OR 5.37, 95% CI 2.37-12.2), and a vertebral fracture (OR 16.6, 95% CI 7.8-31.4) were significantly associated with drug treatment. Bone mineral density measurement was rare (n = 13, 1.1%).

Conclusions: There is under-ascertainment of osteoporosis and modifiable secondary causes in older men with fractures. Fracture does not prompt sufficient bone mineral density measurement or treatment. Information systems merging diagnostic and treatment information can help delineate gaps in patient management. Interventions showing promise in other conditions should be evaluated to improve care for osteoporosis.

Which Long-Term Care Residents Are at High Risk for Adverse Drug Events?

Field TS, Judge J, Rochon P, et al.


Terry S. Field, DSc, Meyers Primary Care Institute/Fallon Healthcare, 630 Plantation Street, Worcester, MA 01605. E-mail: tfield@meyersprimary.org.

Background: Adverse drug events (ADEs) are among the most serious concerns about medication use in residents of long-term care facilities. In a recent study of long-term care residents, we found a rate of 9.8 ADEs per 100 resident-months, of which 4.0 were preventable. To direct prevention efforts, information is needed on factors associated with high risk.

Objective: To assess the factors associated with increased risk of adverse drug events.

Methods: Case-control study nested within a prospective study of ADEs at 2 large, academically affiliated, long-term care facilities.

Results: We identified ADEs in 475 residents. Analyses of age, gender, functional status, burden of illness, and medication use revealed few independent risk factors; all were related to medications. Risk factors included taking anticoagulants (odds ratio (OR) 3.1; 95% confidence interval (CI), 1.7-5.6), antibiotics (OR 1.9; CI 1.3-2.8), antipsychotics (OR 2.4; CI, 1.7-3.5), and anti-epileptics (OR 1.6; CI, 1.1-2.5). Residents taking nonopioid analgesics were at lower risk (OR 0.42; CI, 0.22-0.80). There was a significant dose-response relationship between number of regularly scheduled medications and ADEs. Preventable ADEs occurred in 247 residents. Independent risk factors included taking anticoagulants (OR 2.8; CI, 1.6-4.7), antibiotics (OR 1.7; CI, 1.0-2.7), antipsychotics (OR 3.4; CI, 2.0-5.9), anti-epileptics (OR 2.0; CI, 1.1-3.7), and diuretics (OR 2.2; CI, 1.2-4.0).

Conclusions: Few characteristics were identified to support targeting of efforts specifically to ADE-prone individuals. Prevention should focus on improving medication systems that apply to all residents in long-term care facilities.