Primary prevention: what are we missing in primary care?
Abstract: New health care initiatives call for increased primary prevention in primary care. The National Ambulatory Care Survey surveys physicians on patient care, including delivery of health education. This study investigates opportunities for health education in primary care. There were discrepancies in health education delivered when patients were identified to be at risk versus actual assessments of body mass index, hypertension and other variables. A minority of patients received health education advice, with a downward trend over three years. Additional education is needed related to how physicians can delivery patient-centered health education messages in a clinical setting.
Article Type: Survey
Subject: Social service
Authors: Evans, Marion Willard Jr.
Ndetan, Harrison
Singh, Karan P.
Pub Date: 03/22/2012
Publication: Name: American Journal of Health Studies Publisher: American Journal of Health Studies Audience: Professional Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2012 American Journal of Health Studies ISSN: 1090-0500
Issue: Date: Spring, 2012 Source Volume: 27 Source Issue: 2
Product: Product Code: 9105130 Social Service Support Programs NAICS Code: 92313 Administration of Human Resource Programs (except Education, Public Health, and Veterans' Affairs Programs)
Accession Number: 308741505
Full Text: INTRODUCTION

New health care initiatives introduced by the United States (US) government in 2009-2010 related to access to health care for all Americans accentuate the need for primary prevention (Patient Protection and Affordable Care Act, 2010). As early as 1979, Healthy People (HP) initiatives called for more attention to preventive services and health promotion (US Department of Health and Human Services [USDHHS], 1979). Although some of the HP goals have been met, the efforts continue with the release of initiatives for 2020 (USDHHS, 2009). Both the Institute of Medicine (IOM) and the US Preventive Services Taskforce (USPSTF) have called for more education and training for physicians in primary prevention and population health (IOM, 2002; Agency for Healthcare Research and Quality, 2008). The Institute for Improving Medical Education (Association of Medical Colleges, 2004) and the American Medical Association (AMA) have efforts in place to improve delivery of services aimed at enhancing population health as well (Wilson, 2006).

In spite of efforts to focus primary care providers on primary prevention and health promotion, trends toward overweight, obesity, and physical inactivity continue to increase. Some studies indicate that only a minority of primary care patients receive health education counseling (Kreuter, Cheda, & Bull, 2000; Yarnall, Pollak, 0stbye, Krause, & Michener, 2003; Hayman, Ornish, & Roizen, 2009; Fiore, et al., 2009). Manson and colleagues (2004) called for all health care providers to take action against the growing risks of obesity and sedentary lifestyle. While Americans exercise less and continue to consume less than adequate levels of fruits and vegetables, tobacco use has stabilized at around 20% (Fiore et al., 2009). However, over the past decade, physicians are apparently providing less advice to patients who are overweight or use tobacco (Mokdad, Marks, Stroup, & Gerberding, 2004; Abid, et al., 2005; Thorndike, Regan, & Rigotti, 2007; Hyman et al. 2009).

Most premature deaths in the US are preventable. Typically, studies indicate smoking, overweight, excessive use of alcohol, and lack of physical activity are the causes of premature death for most Americans (Mokdad et al., 2000; USDHHS, 2008). Therefore, part of the solution to providing affordable primary care and decreasing premature morbidity and mortality must be to help patients make healthy behavior changes. Models of health behavior indicate that health care providers are among the most powerful cues to motivate a patient to attempt behavior change (Rimer & Glanz, 2005). Studies indicate that when physicians advise patients to change behavior, most attempt to comply (Kreuter et al., 2000; Ndetan, et al., 2010).

The purpose of this study was to investigate self-reported levels of engagement in general health education (HEd) recommendations by the two primary care physician groups in the United States (medical doctors [MD] and doctors of osteopathy [DO]), as reported through the National Ambulatory Medical Care Survey (NAMCS). Complete details of the NAMCS are available at National Center for Health Statistics (NCHS) webpage at: http://www.cdc.gov/ nchs/ahcd.htm. An assessment of the trend in the provision of HEd counseling was made from 2005-2007. Patient characteristics related to preventable risk factors were noted along with whether the visit was preventive in nature or a routine visit for ambulatory care. In addition, the roles of certain patient characteristics and practice-based covariates that may be potential confounders and/or effect modifiers in the relationship between the provision of HEd services and health care provider type (MD vs DO) were assessed. Box 8 of the NAMCS asks the clinician to check HEd services they rendered on the visit.

METHODS

The study was a secondary analysis of the 2005 to 2007 public release data of the NAMCS. Details on the survey design methodology, data collection, analytical considerations in sampling structure (clustering/stratification), and weights for national population estimates (NPE) are described in detail elsewhere (Tenney, White, & Williamson, 1974). In brief, the NAMCS collects data on medical care provided in physicians' offices in the U.S. Patient visits are selected using a multistage probability sample design with three stages: probability samples of counties, groups of counties, or county equivalents are drawn from all 50 states and District of Columbia, constituting primary sampling units (PSU); a probability sample of practicing physicians is selected within each PSU; and finally a systematic random sample of patient visits is selected within the practices of participating physicians. To be eligible for selection, a physician/ practice must be office-based; principally engaged in patient care; not federally employed; and not in the specialties of anesthesiology, pathology, or radiology.

The basic sampling unit is the physician-patient encounter or "patient visit", and typically excludes telephone calls, visits outside the physician's office (e.g., house calls), visits made in hospital settings (unless the physician had a private office in a hospital), visits made in institutional settings that had primary responsibility for the patient's care (e.g., nursing homes), and visits to the physician's office for administrative purposes only (e.g., to leave a specimen, pay a bill, or pick up insurance forms). Each patient visit is assigned a weight based on four factors: the probability of being selected by the three-stage sampling design; adjustment for nonresponse; adjustment for physician specialty group; and weight smoothing to minimize the impact of a few physician outliers whose final visit weights are large relative to those for the remaining physicians. Data collection is done by the physician/office staff using patient record forms for each selected visit. The overall error, discrepancy and nonresponse rates for most of the variables are usually very low.

DATA MANAGEMENT AND ANALYSES

The electronic files containing the 2005, 2006, and 2007 NAMCS data were acquired from the website (NCHS, 2010). The files were concatenated and analyzed using the Statistical Analysis System (SAS) software, version 9.1.3 (SAS Institute Inc., Cary, NC). Multistage probability design variables for clustering, stratification, and patient visit weights were applied in performing all analyses in order to accurately compute estimates of population parameters and their standard errors.

The 2005 to 2007 combined NAMCS sample had a total of 87,835 individual patient visits resulting in a national population estimate of 2.9 billion physician office visits in the U.S. Surveys from these three years allowed physicians to specify patient tobacco use status, whether the patient was seen specifically for a preventive care visit and whether general, HEd recommendations were provided or ordered. In addition, body mass index (BMI) and blood pressure (BP) were measured. The physician could indicate if non-pharmacological treatments were performed including complementary and alternative medicine (CAM), mental health counseling, and whether the diagnosis included certain co-morbidities such as obesity, diabetes, or hypertension.

The primary outcome variable for this analysis was the provision of HEd counseling to patients during physician office visits from box 8 and other survey indicators. The predictor variables included type of physicians (MD or DO, including physician specialty type); patient demographics (age, sex, race, BMI, BP); modifiable behavior/health condition (tobacco use or exposures, physician-diagnosed obesity, hypertension (HTN) and diabetes); visit-related characteristics (major reason for the visit, length of time spent during the physician-patient encounter, number of previous visits, mode of payment for the visit, and whether the patient was referred for the visit and/or after the visit); as well as practice-related characteristics (type of office setting, ownership of practice, and employment status of physicians). The complete list of variables and levels of categorization is provided in Table 1.

All the variables were re-coded to eliminate invalid and unknown responses. BMI in kg/m2 was categorized as: normal: BMI<25; overweight: BMI [greater than or equal to] 25 to BMI<30; or obese: BMI [greater than or equal to] 30 (CDC-Defining Overweight and Obesity, 2010).

Blood pressure (in mm Hg) that was originally recorded as a systolic and diastolic reading was categorized to address the discordances in the typical 'SBP/DBP' definition as: low/normal: systolic <120 or diastolic<80; at risk for high (borderline hypertension): 12090 or, if the patient was diabetic, systolic [greater than or equal to] 130 or diastolic >80 based on the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure recommendations (Chobanian, et al., 2003).

NPE's (weighted frequencies, weighted percent, and standard errors) for the provision/ordering of HEd services as distributed across all variables listed in Table 1 were derived using the survey clusters, strata, and patient visit weights. Logistic regression models (Hosmer & Lemeshow, 1989) were used to compute odds ratios (ORs) and 95% confidence intervals (CIs) on the likelihood that HEd services were provided/ordered based on each of the listed categorical predictor variables (Table 1).

The provision of HEd services as a function of the time spent during physician-patient encounter and of the number of past visits were analyzed using a multiple linear regression model that controlled for potential confounders. This model was used to compute adjusted means and standard errors of time spent with patients and the number of past visits according to whether or not HEd was provided/ ordered, as well as provider type. The Breslow-Day statistic (Breslow & Day, 1980) was used to assess whether any of the potential predictors was an effect modifier in the relationship between HEd provision and physician type (MD vs. DO). Any variable yielding a 15% difference between the crude and adjusted OR was considered a potential confounder. The final comparison for the general provision of HEd services (DO vs. MDs) was performed using multiple logistic regression that computed adjusted ORs and 95% CIs controlling for identified confounders. All hypotheses were tested at the .05 level of significance.

RESULTS

NATIONAL UTILIZATION ESTIMATES

There were 2.9 billion estimated patient visits to physicians during the years 2005 to 2007 combined, with 21.4 million (7.5%) visits were to DOs and 264.5 million (92.5%) visits to MDs. In aggregate, general HEd was provided or ordered by physicians during an estimated 103.8 million (37.1%) visits. Distribution of this estimate across the patient, visit, and practice characteristics is shown in Table 1. In addition, Table 2 shows the distribution of estimated HEd provision according to physician type.

PHYSICIAN REPORTED LEVELS OF HEALTH EDUCATION

From 2005 to 2007 there was an overall decrease in the number of patients counseled from about 38% of visits in 2005 to 32% in 2006. The percentage increased slightly to 33% in 2007. Statistically significant variation was noted in 2007 with 2005 as referent. A complete breakdown of variables analyzed appears in Table 1.

DEMOGRAPHIC VARIABLES

Using patients aged <15 years as the referent group, there is a trend toward less HEd advice in all other groups through >75 yrs. Variation in reported levels of HEd did not differ based on gender but was segregated by race: black [OR=1.14, 95% CI (1.02,1.27)] and other races [OR=1.36, 95% CI (1.12,1.64)] were advised more than whites.

ADVICE BASED ON PATIENT CHARACTERISTICS OR CONDITIONS

Current smokers were more likely to be advised on tobacco use than non-smokers. Regarding BMI, when calculated by the investigators from recorded height and weight within the sample, and categorized as normal, overweight, or obese according to the standardized table, neither those falling into the overweight or obese categories were advised on HEd more than patients with a normal BMI. However, if the physician coded the patient as obese by ticking a box available near the top of the survey, they were almost 3 times more likely to report providing them with HEd services in the HEd box below, [OR=2.97, 95% CI (2.62,3.38)].

Among patients who had a recorded BP, physicians were less likely to report providing HEd services to those at risk for high BP (borderline hypertension) compared to those with low/normal BP [OR=0.90, 95% CI (0.83,0.98)]. If the physician recorded the patient as hypertensive at the top of the survey, they were more likely to state they gave advice in box 8 [OR=1.36, 95% CI (1.24,1.49)]. If a patient was recorded as diabetic above they were also more likely to have reported giving them advice [OR=1.42, 95% CI (1.28,1.57)].

VISIT CHARACTERISTICS AND ADVICE ON HEALTH EDUCATION

If a patient was seen for a chronic problem, either routine or a flare-up, or seen specifically for a preventive care visit, that patient was more likely to get HEd advice. Patients were less likely to receive HEd advice if the visit was injury-related. Self-pay patients received more HEd than those who paid by other means.

Primary care physicians were more likely to report delivery of HEd for patients on follow-up appointment. Patients who were referred to another doctor, who received diagnostic services, non-pharmacological therapy, disease management program enrollment, or recommendations for complementary and alternative medicine (CAM) services were also more likely to receive HEd advice.

The adjusted national estimates of time spent (in minutes) with the physician during patient visits are presented in Table 3. Included is the number of past visits, distributed according to whether HEd was provided, as well as whether the visit was with an MD or DO. In general, physicians who provided HEd services to patients spent significantly more time ([+ or -] SE) with patients than those who did not provide HEd (20.75 [+ or -] 0.28 min vs 18.93 [+ or -] 0.61 min; p = 0.005). There was no statistically significant difference in the number of past visits between these two groups.

TYPES OF ALLIED HEALTH PROVIDER ENGAGEMENT AND HEALTH EDUCATION

When a nurse (Registered or Licensed Practical) was also seen, the level of HEd increased [OR=1.26 95% CI (1.05,1.53)]. Primary care physicians were more likely to state they performed HEd than surgeons. If a physical therapist (PT), speech therapist, psychotherapist, or other mental health counselor was also seen, the odds of receiving HEd were higher.

HEALTH CENTER, OWNERSHIP CHARACTERISTICS AND COMPUTERIZED PUBLIC HEALTH REPORTING AND HEALTH EDUCATION DELIVERY

Physicians in community health centers were more likely to state they ordered HEd than those in private practice, free-standing clinics, and other types of clinics with solo or group practice as the referent. Some of these differences were not statistically significant. Those stating that the practice was owned by a health maintenance organization (HMO), or those that reported serving in a community health center were somewhat more likely to state they ordered HEd. In this assessment, practice location in a community health center was statistically significant [OR=1.60, 95% CI (1.21, 2.10)] when compared with private solo/group practice for reported HEd.

COMPARISON OF HEALTH EDUCATION ADVICE GIVEN AND PROVIDER TYPE

Table 2 shows data on HEd advice reported, based on physician type (MD or DO). Regarding whether one type performed more HEd with greater frequency, care was taken to account for variations in reported practice settings, allied health provider involvement, and other analyses. Some covariates were effect modifiers. These included BMI status, physician-diagnosed obesity, payment method, use of non-medication therapies including CAM referrals, type of office settings and employment status of the physician. As such, stratum-specific measures of effect are reported in Table 2 for these variables. Tobacco use/exposures, BP, and whether or not the patient was referred for the visit were potential confounders and were adjusted for in the above comparison.

GENERAL HEALTH EDUCATION ADVICE AMONG PROVIDERS

In aggregate, there was a slight difference in levels of advice rendered by DOs when compared to MDs. In weighted estimates this was not statistically significant. Overall, 37.5% (%SE 1.3) of MDs reported they performed HEd services and 37.5% (%SE 2.5) of DOs. Neither group was more likely to engage patients based on smoking status, BMI, obesity as a specifically checked condition, BP or reported HTN status, or diabetic status.

Few differences were noted based on provider type, reason for visit, payment method, physician specialty, or allied health care provider involvement. DOs provided slightly more HEd for self-pay patients [OR=1.81, 95% CI (1.10,2.99)]. DOs were more likely to state they ordered HEd if the patient was treated without medicine, was enrolled in a disease management program, or was referred for mental health counseling. Neither the crude nor adjusted number of past visits nor reported time spent with DOs was significantly different than time spent with MD physicians among those to whom HEd services were provided.

HEALTH EDUCATION, PROVIDER TYPE AND VARIOUS PRACTICE SETTINGS

DOs practicing in an HMO or other prepaid practice were more likely to state they ordered or performed HEd than MDs in those settings [OR=7.80, 95% CI (5.38,11.33)]. The same was true for family practice [OR=11.54, 95% CI (4.74, 28.12)]; if the practice was owned by an HMO [OR=3.24, 95% CI (1.54, 6.81)] or was housed in an academic medical center [OR=2.32, 95% CI (1.02, 5.28)].

DISCUSSION

LIMITATIONS

First, there are specific limitations to secondary data analysis. Data are self-reported, collected in physicians' offices, and not by trained researchers. Some variation may have occured based on respondents' interpretation of the questions. NAMCS participants may differ from those who do not participate. This could include differences in advising rates. There could be variation in need for preventive advice but various health indicators suggest the need is almost universal. The cross-sectional nature of the survey does not allow investigators to determine the kind of advice that may have been rendered on previous or subsequent visits and is only generalizable within these limits.

In spite of the growing need for primary prevention, and perhaps partially because of the widening gap between primary care physicians needed and the number entering the workforce, a minority of doctors report providing HEd advice to patients on a given visit. Despite the need for more primary prevention, it appears that the overall level of engagement did not increase from 2005 to 2007. In this sample < 40% reported delivery of HEd with patients. This is congruent with patient-reported levels of engagement on behaviors such as smoking cessation and advice to lose weight, even though studies emphasize the need for such advice (Manson et al., 2004; Fiore et al., 2009). In addition, some trends noted within the sample are also of concern. For example, when the height and weight reported on the survey were used to calculate BMI, advising rates did not differ significantly among patients categorized in the normal, overweight or obese groups. However, if the physician ticked the box stating the patient was obese, the odds of reporting HEd increased. This may represent missed opportunities for primary prevention among overweight and obese patients. The same was true with blood pressure. That is, doctors tended to report providing HEd if they coded the patient as hypertensive, but, based on classification of the actual reported BP did not predict a greater level of HEd advice among those with "at risk" levels of BP or high BP. This is an interesting finding. If a majority of those with elevated BP were being advised, there would be some indication of this within the calculated "at risk" or HTN category. Therefore, opportunities to advise those at risk for HTN or even those with current HTN may be lost according to this analysis.

LEVELS OF HEALTH EDUCATION AND PRACTICE/ VISIT CHARACTERISTICS

It is worth noting that when a patient specifically saw his or her doctor for chronic conditions or preventive care visits, more HEd advice was delivered. However, when outside services such as diagnostic tests, mental health evaluation or referrals, CAM provider referrals, and referrals to a PT or speech therapists were made, higher levels of HEd were also reported. This may represent a sub-set of the provider base that is practicing a more patient-centered level of care. That is, they make more referrals to other providers when the patient's presentation indicates that such care is most appropriate or desired. However, with the available information, this remains conjecture. It is also noteworthy that when a registered nurse or licensed practical nurse was involved, doctor levels of HEd reported were higher. The growing role and impact of nursing in primary care needs further evaluation.

Physicians in community health centers and academic health centers were somewhat more likely to report HEd than those in private practices. This seems to indicate that those arenas, primary prevention, or at least HEd, is more likely practiced. This could indicate a lack of diffusion into private practices, and seems to show lost opportunities once the physician is out of the academic health system. As to the reason self-pay patients receive more HEd, this can only be speculated upon. It would seem possible that there is a perception that insurance does not pay for HEd so they do not perform it.

PHYSICIANS AND PRIMARY CARE/ PRIMARY PREVENTION

While both MDs and DOs serve as primary care physicians, the osteopathic profession has traditionally had a stronger focus on producing primary care physicians and continues to seek ways to fill primary care voids (Cary, Motyka, Garrett, & Keller, 2003; Shannon, Ferretti, Wood, & Levitan, 2010). However, DOs did not report a significantly greater level of HEd being rendered than did MDs. This is consistent with the previous work of Liccardone and colleagues (2007) who found that patients did see DOs more frequently for prevention than MDs. More emphasis on primary prevention is clearly needed, including how to deliver it in a manner that is cost effective and timely within health care clinics and practices.

CONCLUSION

Based on the interpretation of the results, opportunities for primary prevention may be missed by those in primary care and specialty care alike. A minority of patients are engaged by physicians on HEd based upon physician self-reported data. Trends have not improved. Older patients received less advice and those with chronic conditions were more likely to receive HEd. Inconsistencies are noted in calculated vs. physician-reported levels of risk for overweight/ obese, high BP/HTN and HEd advice aimed at these conditions, which deserves further evaluation. More research is needed relative to patient-centered delivery of care and HEd patterns within and outside of primary medical care, especially when it comes to opportunities to deliver primary prevention.

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Marion Willard Evans, Jr., DC, PhD, MCHES

Harrison Ndetan, MSc, MPH, DrPH

Karan P. Singh, PhD

Marion Willard Evans, Jr., DC, PhD, MCHES, Assistant Dean for Academic Affairs, United States Sports Academy, One Academy Drive, Daphne, AL, mevans@ussa.edu, P: 251-626-3303, Ext 7154, F: 251-6251035. Harrison Ndetan, MSc, MPH, DrPH, Assistant Professor of Research, Parker University Research Institute, 2500 Walnut Hill Lane, Dallas, TX 75229. Karan P. Singh, PhD, Professor/Director BBSF, Department of Medicine, Division of Preventive Medicine, University of Alabama- Birmingham, Medical Towers Building, Suite 647, 1717 11th Avenue, South, Birmingham, AL 35294-4410. The Corresponding Author is Marion Willard Evans, Jr.
Table 1: Distribution of health education services
provided to ambulatory medical care patients in the
United States by patients, physician and practice
characteristics [analysis of NAMCS 2005-2007: total
sample = 87,835; total NPE = 2,859,892,874].

                       Health Education Services
                           Provided/Ordered

                               Yes

Variable            Sample     NPE *     Percent
                    Response             (SE)

Overall               31520    1038.3    37.1 (1.2)

Year

2005                   9476     370.3    35.7 (1.4)
2006                  10943     328.8    31.7 (1.3)
2007                  11101     339.2    32.7 (1.2)

Demographic Characteristics

Age

Under 15               5432     205.2    19.8 (1.1)
years
15-24 years            2589      83.6    8.05 (0.3)
25-44 years            6842     217.4    20.9 (0.6)
45-64 years            9526     301.1    29.0 (0.6)
65-74 years            3618     117.5    11.3 (0.4)
75+ years              3513     113.5    10.9 (0.4)

Sex

Female                18358     607.5    58.8 (0.5)
Male                  13162     430.8    41.5 (0.5)

Race

White                 25771     860.5    82.9 (0.9)
Black                  3772     113.7    10.9 (0.8)
Other                  1977      64.2    6.2 (0.7)

Patient Characteristics/Conditions

Tobacco Use

Not Current           18670     639.8    84.1 (0.6)
Current                3979     121.2    15.9 (0.6)

BMI

Normal                 5102     184.1    40.1 (1.2)
Over Weight            3427     118.8    25.9 (0.7)
Obese                  4495     155.8    34.0 (1.0)

Obesity

No                    28116     924.0    89.0 (0.6)
Yes                    3404     114.3    11.0 (0.6)

Blood Pressure

Low/Normal             6581    228.5.5   36.6 (0.8)
At Risk                6560     236.9    37.9 (0.6)
High                   4568     158.9    25.5 (0.7)

Hypertension

No                    23494     763.1    73.5 (0.8)
Yes                    8026     275.3    26.5 (0.8)

Diabetes

No                    27848     914.8    88.1 (0.5)
Yes                    3672     123.5    11.9 (0.5)

Visit Characteristics

Reason for Visit

New problem            8960     314.5    30.7 (0.6)
  (less than
  3 mos. onset)
Chronic problem,      10534     315.8    30.8 (1.1)
  routine
Chronic problem,       3179      95.9    9.4 (0.5)
  flare-up
Pre-/Post-surgery      1883      54.5    5.3 (0.3)
Preventive care        6591     244.1    23.8 (0.8)

Injury related

No                    28705     944.1    90.9 (0.4)
Yes                    2815      94.2    9.1 (0.4)

Payment Method

Private insurance     15639     573.3    57.5 (1.0)
Medicare               6134     198.2    19.9 (0.7)
Medicaid               4990     145.7    14.6 (0.9)
Worker's                301      10.8    1.1 (0.2)
compensation
Self-pay               1878      44.4    4.5 (0.4)
No charge               336       5.8    0.6 (0.1)
Other                   809      19.2    1.9 (0.2)

Primary care physician

No                    16397     421.0    42.3 (1.5)
Yes                   13795     575.0    57.7 (1.5)

Patient has been seen before

No, new patient        4838     138.8    13.4 (0.4)

Yes,                  26682     899.5    86.6 (0.4)
established
patient

Return PRN

No                    24418     776.9    74.8 (1.1)
Yes                    7102     261.5    25.2 (1.1)

Return, appointment

No                     7945     292.9    28.2 (1.1)
Yes                   23575     745.4    71.8 (1.1)

Referred for visit

No                     8388     219.2    59.2 (1.7)
Yes                    6027     151.4    40.8 (1.7)

Referred to other MD

No                    28979     949.6    91.5 (0.5)
Yes                    2541      88.7    8.5 (0.5)

Diagnostic services ordered/provided

No                     2653      66.8    6.5 (0.5)
Yes                   28464     960.8    93.5 (0.5)

Non-medication therapy ordered/provided

No                    23246     803.0    79.3 (0.8)
Yes                    7387     209.9    20.7 (0.8)

Enrollment status in disease mgmt program

Not enrolled           6351     215.5    66.8 (2.2)
Enrolled               3485     107.3    33.2 (2.2)

Physician Characteristics

Physician M.D. or D.O.

M.D.                  28536     958.9    92.3 (0.8)
D.O.                   2984      79.4    7.7 (0.8)

Physician Assistant seen

No                    30445     993.1    95.6 (0.6)
Yes                    1075      45.2    4.4 (0.6)

Nurse pract/Midwife seen

No                    31010    1023.1    98.5 (0.2)
Yes                     510      15.3    1.5 (0.2)

RN/LPN seen

No                    21977     716.5    69.0 (2.2)
Yes                    9543     321.8    31.0 (2.2)

Other provider seen

No                    26456     874.5    84.2 (1.2)
Yes                    5064     163.8    15.8 (1.2)

Physician Specialty

Primary care          16712     685.1    66.0 (1.4)
Surgical care          5980     146.4    14.1 (0.8)
Medical care           8828     206.8    19.9 (1.1)

Complementary alternative medicine

No                    31149    1028.4    99.0 (0.2)
Yes                     371       9.9    1.0 (0.2)

Physical Therapy

No                    30663    1008.7    97.1 (0.2)
Yes                     857      29.6    2.9 (0.2)

Radiation Therapy

No                    21993     667.4    99.9 (0.0)
Yes                      51       0.6    0.1 (0.0)

Speech/occupational therapy

No                    31408    1035.4    99.7 (0.1)
Yes                     112       3.0    0.29 (0.1)

Psychotherapy

No                    30115    1010.3    97.3 (0.3)
Yes                    1405      28.0    2.7 (0.3)

Other mental health counseling

No                    30608    1015.7    97.8 (0.2)
Yes                     912      22.7    2.2 (0.2)

Practice Characteristics

Type of office setting

Private solo or       25550     926.9    89.3 (1.0)
group practice
Freestanding           1106      50.5    4.9 (0.8)
clinic/
surgicenter
Community              3661      25.4    2.4 (0.5)
health center
Mental health           103       1.6    0.2 (0.0)
center
Non-federal             230       5.8    0.6 (0.2)
government
clinic
Family                   15       0.5    0.1 (0.0)
planning
clinic
HMO/                    728      22.6    2.2 (0.4)
other prepaid
practice
Faculty                 123       4.9    0.5 (0.2)
practice plan
Other                     4       0.0    0.0 (0.0)

Solo or group practice

No                    21439     685.7
                                         66.1(1.7)
Yes                   10071     352.1    33.9 (1.7)

Employment status of physician

Owner                 20366     736.0    70.9 (1.7)
Employee              10121     278.0    26.8 (1.7)
Contractor             1023      23.9    2.3 (0.4)

Who owns the practice

Physician             23636     860.6    82.9 (1.5)
or physician
group
HMO                     760      25.0    2.4 (0.4)
Community              3651      27.9    2.7 (0.4)
health center
Medical/                772      24.2    2.3 (0.5)
academic
health center
Other                  1113      38.8    3.7 (0.6)
hospital
Other                  1319      51.6    5.0 (1.0)
health care
corporation
Other                   255       9.6    0.9 (0.3)

EPUBHLTH Reporting

No                    12748     411.0    81.1 (1.9)
Yes                    3121      96.0    18.9 (1.9)

                       Health Education Services
                            Provided/Ordered

                               No

Variable              Sample   NPE *    Percent
                    Response               (SE)

Overall               15654    1759.6   62.9 (1.2)

Year

2005                  15654    569.7    32.4 (1.2)
2006                  18101    562.0    31.9 (1.0)
2007                  20723    627.9    35.7 (1.3)

Demographic Characteristics

Age

Under 15               7241    273.0    15.5 (0.7)
years
15-24 years            4180    136.7    7.8 (0.3)
25-44 years           11139    360.1    20.5 (0.6)
45-64 years           16321    504.4    28.7 (0.5)
65-74 years            7296    226.8    12.9 (0.4)
75+ years              8301    258.5    14.7 (0.6)

Sex

Female                31365    1028.1   58.4 (0.5)
Male                  23113    731.5    41.6 (0.5)

Race

White                 46004    1502.5   85.4 (0.8)
Black                  5643    174.7    9.9 (0.7)
Other                  2831     82.5    4.7 (0.4)

Patient Characteristics/Conditions

Tobacco Use

Not Current           29163    963.8    87.1 (0.5)
Current                4746    143.0    13.0 (0.5)

BMI

Normal                 6654    227.2    40.0 (0.7)
Over Weight            5178    171.7    30.2 (0.7)
Obese                  5099    169.2    29.8 (0.7)

Obesity

No                    52298    1689.3   96.0 (0.0)
Yes                    2180     70.3    4.0 (0.0)

Blood Pressure

Low/Normal             9338    319.1    34.9 (0.7)
At Risk               10488    367.7    40.2 (0.5)
High                   6679    226.8    24.8 (0.7)

Hypertension

No                    43017    1390.5   79.0 (0.6)
Yes                   11461    369.1    21.0 (0.6)

Diabetes

No                    49714    1606.3   91.3 (0.3)
Yes                    4764    153.3    8.7 (0.3)

Visit Characteristics

Reason for Visit

New problem           17397    639.3    36.9 (0.7)
  (less than
  3 mos. onset)
Chronic problem,      19186    533.4    30.8 (0.9)
  routine
Chronic problem,       4549    136.2    7.9 (0.3)
  flare-up
Pre-/Post-surgery      4483    134.4    7.8 (0.4)
Preventive care        8010    287.2    16.6 (0.7)

Injury related

No                    49706    1582.8   90.0 (0.3)
Yes                    4772    176.7    10.0 (0.3)

Payment Method

Private insurance     26957    908.9    54.3 (1.1)
Medicare              13360    415.6    24.8 (0.9)
Medicaid               6644    205.6    12.3 (0.7)
Worker's                644     25.7    1.5 (0.2)
compensation
Self-pay               2668     74.2    4.4 (0.3)
No charge               291      6.2    0.4 (0.1)
Other                  1253     38.6    2.3 (0.3)

Primary care physician

No                    33671    898.7    54.0 (1.4)
Yes                   18063    766.0    46.0 (1.4)

Patient has been seen before

No, new patient        8032    227.4    12.9 (0.4)

Yes,                  46446    1532.2   87.1 (0.4)
established
patient

Return PRN

No                    41721    1287.9   73.2 (1.0)
Yes                   12757    471.7    26.8 (1.0)

Return, appointment

No                    18078    658.1    37.4 (0.9)
Yes                   36400    1101.5   62.6 (0.9)

Referred for visit

No                    17943    488.9    63.9 (1.6)
Yes                   11364    276.0    36.1 (1.6)

Referred to other MD

No                    51180    1648.3   93.7 (0.3)
Yes                    3298    111.3    6.3 (0.3)

Diagnostic services ordered/provided

No                     9599    265.0    15.2 (0.7)
Yes                   44334    1475.8   84.8 (0.7)

Non-medication therapy ordered/provided

No                    44055    1458.6   84.0 (0.6)
Yes                    9678    277.9    16.0 (0.6)

Enrollment status in disease mgmt program

Not enrolled           9061    308.1    78.2 (2.3)
Enrolled               2729     85.8    21.8 (2.3)

Physician Characteristics

Physician M.D. or D.O.

M.D.                  50421    1627.2   92.5 (0.7)
D.O.                   4057    132.4    7.5 (0.7)

Physician Assistant seen

No                    52494    1686.4   95.8 (0.5)
Yes                    1984     73.2    4.2 (0.5)

Nurse pract/Midwife seen

No                    53558    1726.1   98.1 (0.3)
Yes                     920     33.5    1.9 (0.3)

RN/LPN seen

No                    41367    1297.8   73.8 (2.0)
Yes                   13111    461.7    26.2 (2.0)

Other provider seen

No                    47578    1521.0   86.4 (0.9)
Yes                    6900    238.6    13.6 (0.9)

Physician Specialty

Primary care          22469    955.1    54.3 (1.3)
Surgical care         15967    414.6    23.6 (0.8)
Medical care          16042    389.8    22.2 (1.2)

Complementary alternative medicine

No                    54229    1752.2   99.6 (0.1)
Yes                     249      7.4    0.4 (0.1)

Physical Therapy

No                    53472    1724.5   98.0 (0.2)
Yes                    1006     35.0    2.0 (0.2)

Radiation Therapy

No                    38733    1188.6   99.9 (0.0)
Yes                      91      1.3    0.1 (0.0)

Speech/occupational therapy

No                    54398    1757.5   99.9 (0.0)
Yes                      80      2.1    0.1 (0.0)

Psychotherapy

No                    53032    1733.8   98.5 (0.2)
Yes                    1446     25.8    1.5 (0.2)

Other mental health counseling

No                    53918    1747.5   99.3 (0.1)
Yes                     560     12.1    0.7 (0.1)

Practice Characteristics

Type of office setting

Private solo or       45532    1543.5   87.7(1.46)
group practice
Freestanding           3209    132.1    7.5 (1.5)
clinic/
surgicenter
Community              3998     27.2    1.5 (0.2)
health center
Mental health           295      6.5    0.4 (0.1)
center
Non-federal             221      5.9    0.3 (0.1)
government
clinic
Family                   15      0.8    0.0 (0.1)
planning
clinic
HMO/                   1026     37.5    2.1 (0.4)
other prepaid
practice
Faculty                 167      5.9    0.3 (0.1)
practice plan
Other                    15      0.2    0.0 (0.0)

Solo or group practice

No                    37331    1165.8   66.4 (1.5)
Yes                   17103    591.2    33.6 (1.5)

Employment status of physician

Owner                 37424    1274.2   72.5 (1.4)
Employee              15360    435.3    24.8 (1.3)
Contractor             1650     47.5    2.7 (0.4)

Who owns the practice

Physician             43875    1503.6   85.6 (1.1)
or physician
group
HMO                    1096     38.1    2.2 (0.4)
Community              4108     30.5    1.7 (0.3)
health center
Medical/               1169     39.1    2.2 (0.4)
academic
health center
Other                  1729     57.1    3.3 (0.5)
hospital
Other                  1803     65.6    3.7 (0.7)
health care
corporation
Other                   629     22.0    1.3 (0.3)

EPUBHLTH Reporting

No                    23436    727.6    81.7 (1.8)
Yes                    4996    163.0    18.3 (1.8)

Variable            OR (95% CI)

Overall
Year
2005                        Referent
2006                0.90 (0.77, 1.06)
2007                0.83 (0.71, 0.98)

Demographic Characteristics

Age

Under 15                    Referent
years
15-24 years         0.81 (0.70, 0.95)
25-44 years         0.80 (0.68, 0.94)
45-64 years         0.79 (0.67, 0.94)
65-74 years         0.69 (0.57, 0.83)
75+ years           0.58 (0.49, 0.70)

Sex

Female                      Referent
Male                1.00 (0.94, 1.05)

Race

White                       Referent
Black               1.14 (1.02, 1.27)
Other               1.36 (1.12, 1.64)

Patient Characteristics/Conditions

Tobacco Use
Not Current                 Referent
Current             1.28 (1.15, 1.41)

BMI

Normal                      Referent
Over Weight         0.85 (0.77, 0.95)
Obese               1.14 (1.00, 1.29)

Obesity

No                          Referent
Yes                 2.97 (2.62, 3.38)

Blood Pressure

Low/Normal                  Referent
At Risk             0.90 (0.83, 0.98)
High                0.98 (0.89, 1.08)

Hypertension

No                          Referent
Yes                 1.36 (1.24, 1.49)

Diabetes

No                          Referent
Yes                 1.42 (1.28, 1.57)

Visit Characteristics
Reason for Visit

New problem                 Referent
  (less than
  3 mos. onset)
Chronic problem,    1.43 (1.25, 1.64)
  routine
Chronic problem,    1.20 (1.10, 1.32)
  flare-up
Pre-/Post-surgery   0.83 (0.71, 0.96)
Preventive care     1.73 (1.54, 1.94)

Injury related

No                          Referent
Yes                 0.89 (0.80, 0.99)

Payment Method

Private insurance   1.05 (0.87, 1.27)
Medicare            0.80 (0.64, 0.98)
Medicaid            1.18 (0.96, 1.46)
Worker's            0.70 (0.49, 1.01)

compensation

Self-pay                    Referent
No charge           1.57 (0.91, 2.72)
Other               0.83 (0.59, 1.16)

Primary care physician

No                          Referent
Yes                 1.60 (1.40, 1.83)

Patient has been seen before

No, new patient             Referent

Yes,                0.96 (0.88, 1.05)
established
patient

Return PRN

No                          Referent
Yes                 0.92 (0.82, 1.03)

Return, appointment

No                          Referent
Yes                 1.52 (1.36, 1.70)

Referred for visit

No                          Referent
Yes                 1.22 (1.05, 1.43)

Referred to other MD

No                          Referent
Yes                 1.39 (1.23, 1.56)

Diagnostic services ordered/provided

No                          Referent
Yes                 2.58 (2.11, 3.17)

Non-medication therapy ordered/provided

No                          Referent
Yes                 1.37 (1.23, 1.53)

Enrollment status in disease mgmt program

Not enrolled                Referent
Enrolled            1.79 (1.39, 2.30)

Physician Characteristics

Physician M.D. or D.O.

M.D.                        Referent
D.O.                1.02 (0.80, 1.23)

Physician Assistant seen

No                          Referent
Yes                 1.05 (0.79, 1.39)

Nurse pract/Midwife seen

No                          Referent
Yes                 0.77 (0.55, 1.09)

RN/LPN seen

No                          Referent
Yes                 1.26 (1.05, 1.53)

Other provider seen

No                          Referent
Yes                 1.19 (0.98, 1.46)

Physician Specialty

Primary care                Referent
Surgical care       0.49 (0.42, 0.57)
Medical care        0.74 (0.62, 0.88)

Complementary alternative medicine

No                          Referent
Yes                 2.29 (1.26, 4.16)

Physical Therapy

No                          Referent
Yes                 1.45 (1.17, 1.79)

Radiation Therapy

No                          Referent
Yes                 0.87 (0.48, 1.58)

Speech/occupational therapy

No                          Referent
Yes                 2.39 (1.50, 3.81)

Psychotherapy

No                          Referent
Yes                 1.87 (1.38, 2.52)

Other mental health counseling

No                          Referent
Yes                 3.23 (2.23, 4.69)

Practice Characteristics

Type of office setting

Private solo or             Referent
group practice
Freestanding          0.6 (0.4, 0.9)
clinic/
surgicenter
Community             1.6 (1.1, 2.2)
health center
Mental health         0.4 (0.2, 0.8)
center
Non-federal           1.6 (0.9, 3.1)
government
clinic
Family                1.1 (0.2, 5.7)
planning
clinic
HMO/                  1.0 (0.7, 1.5)
other prepaid
practice
Faculty               1.4 (0.6, 3.3)
practice plan
Other                 0.4 (0.4, 0.5)

Solo or group practice

No                          Referent
Yes                   1.0 (0.9, 1.2)

Employment status of physician

Owner                       Referent
Employee              1.1 (1.0, 1.3)
Contractor            0.9 (0.6, 1.2)

Who owns the practice

Physician                   Referent
or physician
group
HMO                   1.2 (0.8, 1.7)
Community             1.6 (1.2, 2.1)
health center
Medical/              1.1 (0.7, 1.6)
academic
health center
Other                 1.2 (0.9, 1.6)
hospital
Other                 1.4 (1.0, 1.9)
health care
corporation
Other                 0.8 (0.4, 1.3)

EPUBHLTH Reporting

No                          Referent
Yes                   1.0 (0.8, 1.3)

Percent (SE) = Percent of NPE (Standard Error).

OR (95% CI) = Crude Odds Ratio (95% Confidence
Interval) for the provision of health education
counseling (yes/no).

M.D. = Doctor of Medicine

D.O. = Doctor of Osteopathic Medicine

BMI = Body mass index

RN = Registered Nurse

LPN = Licensed Practical Nurse

HMO = Health Maintenance Organization

EPUBHLTH = Practice has computer system for
public health reporting.
* Table entries for NPE are reported in millions.

Table 2: National population estimates (NPE) of
health education services provided/ordered by United
States allopathic/osteopathic physicians in
ambulatory medical care [analysis of NAMCS 2005-2007:
total sample = 31,520; total NPE = 1,038,348,276].

                    Health Education Services
                       Provided/Ordered by

                             M.D.

Variable          Sample     NPE *   Percent
                  Response           (SE)

Overall           28536      958.9   37.5 (1.3)

Year
2005              8571       342.1   35.7 (1.4)

2006              9820       306.4   32.0 (1.3)
2007              10145      310.5   32.4 (1.2)

Demographic Characteristics

Age

Under 15 years    5143       197.5   20.6 (1.1)
15-24 years       2317       76.7    8.0 (0.3)
25-44 years       6071       196.8   20.5 (0.6)
45-64 years       8479       273.0   28.5 (0.6)
65-74 years       3293       109.0   11.4 (0.4)
75+ years         3233       106.1   11.1 (0.5)

Sex

Female            16570      561.5   58.6 (0.5)
Male              11966      397.4   41.4 (0.5)

Race

White             23180      790.2   82.4 (0.1)
Black             3528       108.2   11.3 (0.8)
Other             1828       60.4    6.3 (0.7)

Patient Characteristics/Conditions

Tobacco Use

Not Current       16975      595.3   84.5 (0.6)
Current           3500       108.9   15.5 (.06)

BMI

Normal            4590       170.8   41.1 (1.3)
Over Weight       2959       106.4   25.6 (0.7)
Obese             3878       138.3   33.3 (1.0)

Obesity

No                25569      855.3   89.2 (0.6)
Yes               2967       103.6   10.8 (0.6)

Blood Pressure

Low/Normal        5899       211.1   37.1 (0.9)
At Risk           5695       213.2   37.5 (0.7)
High              4004       144.2   25.4 (0.7)

Hypertension

No                21393      706.3   73.7 (0.8)
Yes               7143       252.6   26.3 (0.8)

Diabetes

No                25283      845.2   88.1 (0.5)
Yes               3253       113.7   11.9 (0.5)

Visit Characteristics

Reason for Visit

New problem       7987       287.7   30.4 (0.7)
(less than 3
mos. onset)
Chronic           9557       289.7   30.6 (1.1)
problem,
routine
Chronic           2823       87.3    9.2 (0.5)
problem,
flare-up
Pre-/Post-        1766       50.8    5.4 (0.3)
surgery
Preventive        6058       230.4   24.4 (0.9)
  care

Injury related

No                26111      876.2   91.4 (0.4)
Yes               2425       82.7    8.6 (0.4)

Payment Method

Private           14222      530.6   57.6 (1.1)
insurance
Medicare          5565       183.7   19.9 (0.7)
Medicaid          4519       135.8   14.8 (1.0)
Worker's          261        9.5     1.0 (0.2)
  compensation
Self-pay          1586       38.5    4.2 (0.3)
No charge         307        5.7     0.6 (0.2)
Other             738        16.8    1.8 (0.2)

Primary care physician
No                11978      528.4   57.4 (1.6)
Yes               15396      392.3   42.6 (1.6)

Patient has been seen before

No, new patient   4441       127.6   13.3 (0.5)
Yes,              24095      831.3   86.7 (0.5)
  established
  patient

Return PRN

No                22131      716.9   74.8 (1.2)
Yes               6405       242.1   25.2 (1.2)

Return, appointment

No                7143       270.2   28.2 (1.1)
Yes               21393      688.7   71.8 (1.1)

Referred for visit

No                5736       141.5   41.1 (1.8)
Yes               7746       203.0   58.9 (1.8)

Referred to other MD

No                26312      877.8   91.5 (0.5)
Yes               2224       81.1    8.5 (0.5)

Diagnostic services ordered/provided

No                2476       61.6    6.5 (0.6)

                    Health Education Services
                       Provided/Ordered by

                             D.O.

Variable          Sample     NPE *   Percent
                  Response           (SE)

Overall           9476       370.3   37.5 (2.5)

Year

2005              905        28.3    35.6 (3.3)
2006              1123       22.4    28.2 (3.8)
2007              956        28.8    36.2 (3.4)

Demographic Characteristics

Age

Under 15 years    289        7.8     9.8 (1.9)
15-24 years       272        6.9     8.7 (0.8)
25-44 years       771        20.6    25.9 (1.3)
45-64 years       1047       28.2    35.4 (1.3)
65-74 years       325        8.6     10.8 (0.6)
75+ years         280        74.7    9.4 (1.0)

Sex

Female            1788       46.0    57.9 (1.4)
Male              1196       33.5    42.1 (1.4)

Race

White             2591       70.3    88.4 (1.3)
Black             244        5.5     6.9 (0.9)
Other             149        3.7     4.7 (0.9)

Patient Characteristics/Conditions

Tobacco Use

Not Current       1695       44.5    78.4 (1.7)
Current           479        12.3    21.6 (1.7)

BMI

Normal            512        13.3    30.9 (1.7)
Over Weight       468        12.3    28.7 (1.3)
Obese             617        17.4    40.4 (1.7)

Obesity

No                2547       68.7    86.5 (1.6)
Yes               437        10.8    13.5 (1.6)

Blood Pressure

Low/Normal        682        17.3    31.1 (1.9)
At Risk           865        23.6    42.5 (1.9)
High              564        14.7    26.4 (1.7)

Hypertension

No                2101       56.8    71.5 (1.9)
Yes               883        22.6    28.5 (1.9)

Diabetes

No                2565       69.6    87.6 (0.9)
Yes               419        9.9     12.4 (0.9)

Visit Characteristics

Reason for Visit

New problem       973        26.8    33.9 (1.7)
(less than 3
mos. onset)
Chronic           977        26.1    33.0 (1.8)
problem,
routine
Chronic           356        8.6     10.9 (1.6)
problem,
flare-up
Pre-/Post-        117        3.8     4.8 (1.2)
surgery
Preventive        533        13.7    17.4 (2.1)
  care

Injury related

No                2594       67.9    85.5 (1.7)
Yes               390        11.6    14.5 (1.7)

Payment Method

Private           1417       42.7    55.6 (2.4)
insurance
Medicare          569        14.5    18.9 (1.4)
Medicaid          471        10.0    13.0 (1.9)
Worker's          40         1.3     1.7 (0.5)
  compensation
Self-pay          292        5.9     7.7 (1.7)
No charge         29         0.1     0.1 (0.1)
Other             71         2.3     3.0 (1.1)

Primary care physician

No                1817       46.5    61.8 (4.2)
Yes               1001       28.8    38.2 (4.2)

Patient has been seen before

No, new patient   397        11.2    14.1 (1.4)
Yes,              2587       68.2    85.9 (1.4)
  established
  patient

Return PRN

No                2287       60.0    75.6 (2.0)
Yes               697        19.4    24.4 (2.0)

Return, appointment

No                802        22.7    28.6 (1.9)
Yes               2182       56.7    71.4 (1.9)

Referred for visit

No                291        9.8     37.8 (5.4)
Yes               642        16.2    62.2 (5.4)

Referred to other MD

No                2667       71.8    90.4 (1.0)
Yes               317        7.7     9.6 (1.0)

Diagnostic services ordered/provided

No                177        5.2     6.5 (1.7)

Variable          OR (95%
                  CI)

Overall           1.30 (1.24,
                  1.37)[dagger]
                  1.02 (0.81,
                  1.28)
Year

2005              1.02 (0.81,
                  1.23) ([double
                  dagger])
2006
2007

Demographic Characteristics

Age

Under 15 years    1.03 (0.82,
                  1.30) ([double
                  dagger])
15-24 years
25-44 years
45-64 years
65-74 years
75+ years

Sex

Female            1.02 (0.81,
                  1.28)([double
                  dagger])
Male

Race

White             1.03 (0.82,
                  1.30) ([double
                  dagger])
Black
Other

Patient Characteristics/Conditions

Tobacco Use

Not Current       0.88 (0.70,
                  1.10) ([double
                  dagger])
Current

BMI

Normal            0.64 (0.45,
                  0.91) ([pounds
                  sterling])
Over Weight       0.95 (0.68,
                  1.34)
Obese             0.82 (0.61,
                  1.09)

Obesity

No                1.00 (0.79,
                  1.28) ([pounds
                  sterling])
Yes               0.91 (0.67,
                  1.25)
Blood Pressure
Low/Normal        0.91 (0.71,
                  1.15) ([double
                  dagger])
At Risk
High

Hypertension

No                1.01 (0.81,
                  1.27) ([double
                  dagger])
Yes

Diabetes

No                1.01 (0.81,
                  1.28) ([double
                  dagger])
Yes

Visit Characteristics

Reason for Visit

New problem       1.05 (0.84,
(less than 3      1.32) ([double
mos. onset)       dagger])
Chronic
problem,
routine
Chronic
problem,
flare-up
Pre-/Post-
surgery
Preventive
  care

Injury related

No                1.02 (0.81,
                  1.29)([double
                  dagger])
Yes

Payment Method

Private           0.95 (0.74,
insurance         1.22) ([pounds
                  sterling])
Medicare          1.12 (0.84,
                  1.49)
Medicaid          0.93 (0.60,
                  1.45)
Worker's          1.49 (0.64,
  compensation    3.46)
Self-pay          1.81 (1.10,
                  2.99) ([pounds
                  sterling])
No charge         0.70 (0.16,
                  3.01)
Other             1.17 (0.44,
                  3.12)

Primary care physician

No                0.95 (0.76,
                  1.19) ([double
                  dagger])
Yes

Patient has been seen before

No, new patient   1.02 (0.81,
                  1.28) ([double
                  dagger])
Yes,
  established
  patient

Return PRN

No                1.02 (0.81,
                  1.28) ([double
                  dagger])
Yes

Return, appointment

No                1.03 (0.82,
                  1.29) ([double
                  dagger])
Yes

Referred for visit

No                1.18 (0.79,
                  1.75) ([double
                  dagger])
Yes

Referred to other MD

No                1.01 (0.80,
                  1.28) ([double
                  dagger])
Yes

Diagnostic services ordered/provided

No                1.00 (0.79,
                  1.25) ([double
                  dagger])

Table 3: Adjusted national estimates of time spent
(in minutes) with physician during patient visits and
number of past visits, distributed as to whether
HEd was provided or not and whether the visit
was with an

MD or DO

                 Overall   Among    No       Diff.    P-value
                 Mean      Hed      Hed      Mean
                 (SE)      Mean     Mean     (SE)
                           (SE)     (SE)

Time spent       19.53     20.75    18.93    1.83     0.005
with patient     (0.40)    (0.28)   (0.61)   (0.64)
Number           3.76      3.77     3.76     0.01     0.94
of past          (0.04)    (0.04)   (0.06)   (0.07)
visits in last
12months

MD or DO

                           Among HEd

                 Among     Among     Diff     P-value
                 MD Mean   DO Mean   Mean
                 (SE)      (SE)      (SE)

Time spent       20.76     20.73     0.02     0.98
with patient     (0.30)    (0.76)    (0.82)
Number           3.74      4.14      0.41     0.14
of past          (0.04)    (0.27)    (0.28)
visits in last
12months
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