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Primary prevention: what are we missing in primary
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| 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. |
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| 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. 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): 120 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. REFERENCES Abid, O., Galuska, D., Khan, L. K., Gillespie, D., Ford, E. S., & Serdula M. K. (2005) Are healthcare professionals advising obese patients to lose weight: a trend analysis. Medscape General Medicine, 7(4). Retrieved from http://www.medscape.com Agency for Healthcare Research and Quality. (2009). The Guide to Clinical Preventive Services. Recommendations of the U.S. Preventive Services Task Force. September, 2008. Retrieved from http:// www.ahrq.gov/clinic/prevenix.htm Association of Medical Colleges. (2004). Educating Doctors to Provide High Quality Medical Care: A Vision for Medical Education in the United States. Report of the Ad-hoc Committee Deans. Institute for Improving Medical Education. Retrieved from http://services.aamc.org/publications/showfile.cfm?file=version27. pdf Breslow, N. E., & Day, N. E. (1980). Unconditional logistic regression for large strata. In: N. E. Breslow and N. E. Day (eds.), Statistical Methods in Cancer Research Volume I. The Analysis of Case-Control Studies, (pp. 192-244). Lyon, France: IARC. Cary, T. S., Motyka, T. M., Garrett, J. M., & Keller, R. B. (2003) Do osteopathic physicians differ inpatient interaction from allopathic physicians? An empirically derived approach. Journal of the American Osteopathic Association, 103, 313-318. Centers for Disease Control and Prevention. (2010). Defining Overweight and Obesity: Definition for Adults. Retrieved from http://www.cdc.gov/obesity/defining.html Chobanian, A. V., Bakris, G. L., Black, H. R., Cushman, W. C., Green, L. A., Izzo, J. L. Jr,...Roccella, E. J. (2003). 7th Report, Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension 42,1206-1252. Fiore, M. C., Jaen, C. R., Baker, T. B., Bailey, W. C., Benowitz, N. L., Curry, S. J.,... Wewers, M. E. (2009) Treating Tobacco Use and Dependence: 2008 Update. (Quick Update for Clinicians. United States Department of Health and Human Services, Public Health Service, Rockville, MD. Hosmer, D. W., & Lemeshow, S. (1989). Applied Logistic Regression. John Wiley & Sons, New York, N.Y. Hyman, M. A., Ornish, D., & Roizen, M. (2009). Lifestyle medicine: Treating the cause of disease. Alternative Therapies in Health and Medicine, 15, 12-14. Institute of Medicine. (2002). Who Will Keep the Public Healthy? Educating Public Health Professionals for the 21st Century. The National Academies Press. Washington, DC. Retrieved from http://www.nap.edu/ openbook.php?isbn=030908542X Kreuter, M. W., Chheda, S. G., & Bull, F. C. (2000). How does physician advice influence patient behavior? Evidence of a priming effect. Archives of Family Medicine, 9, 426-433. Licciardone, J. C. (2007). A comparison of patient visits to osteopathic and allopathic general and family medicine physicians: results from the National Ambulatory Medical Care Survey, 2003-2004. Osteopathic Medicine and Primary Care, 1:2 doi:10.1186/1750-4732-1-2. Manson, J. E., Skerrett, P. J., Greenland, P., & VanItallie, T. B. (2004) The escalating pandemics of obesity and sedentary lifestyle. Archives of Internal Medicine, 164, 249-258. Mokdad, A. H., Marks, J. S., Stroup, D.F., & Gerberding J. L. (2004). Actual causes of death in the United States, 2000. Journal of the American Medical Association, 291, 1238-1245. Morrato, E. H., Hill, J. O., Wyatt, H. R., Ghushchyan, V., & Sullivan, P. W. (2006). Are health care professionals advising patients with diabetes or at risk for developing diabetes to exercise more? Diabetes Care, 29, 543-548. National Center for Health Statistics. 2005-2007 NAMCS Downloadable Data File. Retrieved from ftp:// ftp.cdc.gov/pub/Health_Statistics/NCHS/Dataset_Documentation/ NAMCS/ Ndetan, H., Evans, M. W., Bae, S. Fellini, M., Rupert, R., & Singh, K. P. (2010). The health care provider's role and patient compliance to health promotion advice from the user's perspective: Analysis of the 2006 National Health Interview Survey Data. Journal of Manipulative Physiological Therapeutics, 33, 413-418. Patient Protection and Affordable Care Act (2010). The White House. Retrieved from http://www. whitehouse.gov/healthreform/healthcare-overview Rimer, B. K., & Glanz, K. (2005). Theory at a Glance: A Guide for Health Promotion Practice. 2nd ed. National Institutes for Health. National Cancer Institute. Publication No. 05-3896, Washington, D.C. Shannon, S. C., Ferretti, S. M., Wood, D., & Levitan, T. (2010) The challenges of primary care and innovative responses in osteopathic education. Health Affairs, 29, 1015-1022. Tenney, J. B., White, K. L., & Williamson, J.W. (1974). National Ambulatory Medical Care Survey: Background and Methodology. Volume Series 2, No. 61. National Center for Health Statistics, Hyattsville, MD. Thorndike, A. N., Regan, S., & Rigotti, N. A. (2007). The treatment of smoking by U.S. physicians during ambulatory visits 1994-2003. American Journal of Public Health, 97,1878-1883. United States Department of Health and Human Services. (1979). Healthy People: The Surgeon General's Report of Health Promotion and Disease Prevention. Public Health Service. Office of Assistant Secretary for the Surgeon General. Publication no. 79-55071, Washington D.C. United States Department of Health and Human Services. (2009). Healthy People 2020: The Road Ahead. Retrieved from http://www.healthypeople.gov/hp2020/ United States Department of Health and Human Services. (2008). 2008 Physical Activity Guidelines for Americans: Be Active, Healthy and Happy. Retrieved from http://www.health.gov/paguidelines/guidelines/ default.aspx Wilson, C. B. (2009). Health System Reform: What Does the Future Hold? American Medical Association Florida Grand Rounds, Orlando, FL. August 5, 2009. Retrieved from http://www.ama-assn.org/ama/ pub/news/speeches/wilson-florida-hospital-hsr.shtml Yarnall, K. S. H., Pollak, K. I., 0stbye, T., Krause, K. M., & Michener, J. L. (2003). Primary care: is there enough time for prevention? American Journal of Public Health, 93, 635-641. 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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