Changes In Functional Status Related To health Maintenance Visits To Family Physicians
Enrolled patients were randomized into 2 groups in a 1:2 ratio: an observation-only group and a group that received a debriefing interview after their visit to the family practice clinician. As they left the examination room, the interview group was asked to complete a brief questionnaire that included a patient satisfaction instrument, the Patient/Doctor Interaction Scale (PDIS),19 and a debriefing instrument. The debriefing instrument addressed the patient’s views about the visit, specific behavioral changes recommended by the provider (with no preset response set), patient’s perception of the need for behavioral change, methods suggested to accomplish the change, and the patient’s perception of the likelihood of success in accomplishing the change. The PDIS is a 17-item patient satisfaction scale that assesses the portion of patient satisfaction involving interactions with the physician; we modified it slightly by adding 3 more general satisfaction questions. It was developed and validated in a family practice office and has been shown to be related to higher recall rates.20 The scale has balanced positive and negative questions, uses a 5-point scale, and has an adequate completion rate. The clinicians were also asked to complete a brief questionnaire characterizing their perceptions of encounters with patients enrolled in both groups.
There was telephone follow-up of all patients at 1 month and 3 months after the visit to the clinician. A maximum of 6 attempts was made to contact participants. The telephone calls included repeat administration of the DUKE to assess functional status, questions about additional visits to the clinician or other healthcare providers, and about progress toward achieving recommended behavioral changes. We included all data in the analysis, in concordance with the intention-to-treat principle.
Data from completed forms were entered into a database by a trained, experienced research assistant. Before entry, each form was inspected for completeness, ambiguity of responses, or other irregularities. All unclear responses were referred to the investigators. Range checks were conducted periodically as data were entered to detect errors and were repeated as part of the data cleaning procedures before analysis. Descriptive statistics were calculated on all variables, including the DUKE subscale scores and the PDIS scores. Initial statistical analysis was carried out to test for differences in DUKE means between patients randomized to the observation-only group and the debriefing group. Differences in the PDIS and DUKE subscale means were tested at baseline, 1 month, and 3 months using a repeated measures approach (SAS subroutine PROC MIXED, SAS Institute, Cary, NC).
Results
We recruited participants during a 9-month period beginning in September 1995. Including the 3-month follow-up period, data collection was completed in 12 months. Of the 208 patients recruited, 68 (34%) were randomized to the observation-only group, and 132 (68%) were assigned to receive the debriefing interview. In the observation-only group, 64 (94%) patients were successfully contacted for the 1-month assessment, and 62 (91%) for the 3-month assessment. Of the 132 patients assigned to the debriefing group, 2 refused to complete the debriefing interview. Of those completing the debriefing interview, 123 (93%) were successfully contacted for the 1-month assessment, and 122 (92%) for the 3-month assessment.
The average age of the enrolled patients was 47.4 years (standard deviation [SD] =11.9, range=19-76 years) and 68.0% were women; 32.5% were African American, 65.0% were white, and the rest represented a variety of ethnic groups Table 1. The average educational level of the patients was 14.2 years (SD=3.0). A percent of 12.8 reported annual family incomes less than $15,000, 13.4% between $15,000 and $25,000, and more than half had incomes of $35,000 or more. The interview group had higher income levels than the observation group; otherwise there were no significant differences.
The reasons for patient visits were Papanicolaou tests, pelvic examinations, and routine health maintenance, although some of these visits incorporated a follow-up of a chronic condition. No statistically significant differences were found between the study groups by reason for visit. After the visits, 63 (48%) of the 132 patients in the interview group reported that their clinician recommended a specific type of behavioral change. Of the patients reporting having been given a recommendation, 11 were asked to quit smoking; 15 to change medications or the way that medications were taken; 33 to alter their diet, exercise level, or lose weight; and 4 received recommendations related to stress reduction. Additional miscellaneous changes were also recommended. It is interesting that patients sometimes reported some form of mental health behavioral change, but alcohol was only mentioned rarely by the patients. We expected behavioral changes related to alcohol use or abuse to be mentioned frequently.
