Changes In Functional Status Related To health Maintenance Visits To Family Physicians

PDIS assessment only occurred at baseline. The mean PDIS score for all observations was 55.8 (SD=5.5, range=35-66). No significant differences in satisfaction were found between the observation and interview groups, and there was no difference in patient satisfaction found between patients who reported receiving a recommendation for behavioral change and those who did not.

We performed the analysis of the outcomes (ie, changes in functional status by recommendation to change behavior), in 2 steps. In the first step, we examined the effect of the debriefing interview by comparing the DUKE subscale scores for the interview and observation groups at 1 month and 3 months. No significant differences were found for any of the DUKE subscales. Based on results indicating that the debriefing interviews had no effect on outcomes, we created 2 groups for subsequent analyses. One group consisted of patients who reported that they received behavioral change recommendations. The second group included all other patients enrolled in the study. This is a conservative method that would tend to underestimate differences because a portion of the observation group may have received behavioral change recommendations. Analysis of differences between these 2 groups during the 3 observations was carried out using a repeated measures approach. A repeated measures model (using SAS PROC MIXED) was fit for each of the DUKE subscale means. The model included time of assessment (baseline, 1 month, 3 months), race, age, sex, and educational level as independent variables. Table 1, Table 2 shows the means for each of the DUKE subscales at each assessment for patients who did and did not receive recommendations to change behavior. As Table 2 indicates, no significant differences (P <.05) were found between patients who did and did not receive a recommendation to change behavior at baseline. At the 1-month follow-up assessment, the mean scores for mental health, social health, and self-esteem were lower for patients who received a behavioral change recommendation. At 3 months, the differences in mental, social, and self-esteem found at 1 month persisted, and the means coresforanxiety, anxiety/depression, and depression were worse for patients receiving recommendations. Race and sex were not significantly associated with differences for any of the DUKE subscale scores shown in Table 2. Education, however, was significantly associated with every subscale. Age was associated with self-esteem. The functional status scores for patients who received recommendations to change behavior declined as educational level increased. Older, better-educated patients who received behavioral change recommendations were the most likely to report reduced functional status and self-esteem during the 3-month follow-up period. Finally, as the results in Table 2 show, the effects observed in the patients who received recommendations were consistent at the 1-month and 3-month assessments. The differences were all in the negative direction except for the pain subscale score. Reports of pain decreased from the baseline to the 1-month assessment and then were higher at the 3-month assessment.

The Effect of Specific Recommendations

To further investigate influences on DUKE subscale scores, we evaluated the effect of the type of change recommended by the clinician for patients given a specific type of recommendation.

Four categories of recommended changes were found: medication compliance, diet and exercise, smoking cessation, and stress control. Table 3 shows the mean DUKE subscale scores by the type of change recommended. As Table 3 indicates, statistically significant differences among the mean scores by type of change recommended were found at the 3-month assessment for disability, mental health, and self-esteem. Post hoc examination of the mean scores in these cases suggested that disability scores for patients who were asked to stop smoking were worse than those of patients asked to improve medication compliance or change their diet. Mental health scores for patients who were asked to stop smoking were significantly poorer than for those asked to try to control stress. No group differences were found for self-esteem scores.

Discussion

The results from our study provide further support that certain elements of patient functioning decline 3 months after behavioral change is recommended by a clinician. These results confirm our previous findings¹¹ and those reported by others.¹² We found that social and emotional functioning varied according to whether the patient reported that their clinician recommended that they change a behavior. The observation group had functional declines similar to the entire interview group; the declines fell intermediately between those of patients who reported being asked to make behavioral changes (who had functional declines) and those who reported no behavioral changes (who had no functional declines). This suggests that the debriefing after the office visit had no impact on the outcomes, and reinforces that it was the behavioral change recommendation that led to the declines in self-reported functional status.