Family Medicine Outpatient Encounters are More Complex Than Those of Cardiology and Psychiatry

The Journal of the American Board of Family Medicine

Carlos Roberto Jaén¹  David Katerndahl¹  Robert Wood¹ 

[1]Departments of Family and Community Medicine (DK, RW, CRJ)

关键词: Family Practice;    Nonlinear Dynamics;    Quality of Care;    Specialization;    Systems Theory;   

DOI  :  10.3122/jabfm.2011.01.100057

学科分类：过敏症与临床免疫学

来源: The American Board of Family Medicine

【 摘 要 】

Background: Comparison studies suggest that the guideline-concordant care provided for specific medical conditions is less optimal in primary care compared with cardiology and psychiatry settings. The purpose of this study is to estimate the relative complexity of patient encounters in general/family practice, cardiology, and psychiatry settings.

Methods: Secondary analysis of the 2000 National Ambulatory Medical Care Survey data for ambulatory patients seen in general/family practice, cardiology, and psychiatry settings was performed. The complexity for each variable was estimated as the quantity weighted by variability and diversity.

Results: There is minimal difference in the unadjusted input and total encounter complexity of general/family practice and cardiology; psychiatry's input is less complex. Cardiology encounters involved more input quantitatively, but the diversity of general/family practice input eliminated the difference. Cardiology also involved more complex output. However, when the duration of visit is factored in, the complexity of care provided per hour in general/family practice is 33% more relative to cardiology and 5 times more relative to psychiatry.

Conclusions: Care during family physician visits is more complex per hour than the care during visits to cardiologists or psychiatrists. This may account for a lower rate of completion of process items measured for quality of care.

• Family Practice
• Nonlinear Dynamics
• Quality of Care
• Specialization
• Systems Theory

Although ecological studies consistently find that the supply of primary care physicians is associated with better quality of care, better population health, and lower cost of care,¹ there is a sizable body of literature suggesting that, compared with generalists, specialists are more likely to provide effective disease-specific care, but at a cost of increased resource use and hospital stays.² Comparison studies suggest that the process quality of care provided for specific medical conditions is poorer in primary care than in specialty settings.

Specifically, when comparing generalists with cardiologists, family physicians more often recommend therapies, which are less beneficial for acute myocardial infarction, than do cardiologists,^3,4 with an inconsistent finding of higher mortality.^5,6 Similarly, patients with unstable angina are less likely to receive effective treatments if treated by generalists rather than cardiologists.^7,8 In addition, compared with generalists, cardiologists are less likely to order tests but prescribe more medications for hypertension and ischemic heart disease.⁹ Cardiologists also perform more cardiac catheterizations,¹⁰ more echocardiograms, and prescribe more evidence-based medications for patients with heart failure.^11,12 Consequently, patients hospitalized for heart failure had higher short-term¹³ and long-term¹⁴ mortality rates if cared for by generalists. However, because the patients seen by family physicians often differed significantly from those seen by cardiologists in many demographic and clinical features, it is difficult to know whether statistical adjustment in these observational studies was adequate to control for such differences.

Similar differences between primary care physicians’ and psychiatrists’ treatment of patients with mental disorders have been reported. Studies suggest that, compared with psychiatrists, primary care physicians more often fail to detect mental disorders,^15–17 make more diagnostic errors,^18,19 and more often use inappropriate or inadequate dosages of psychotropic medications.^20,21 However, not every study comparing psychiatrists and primary care physicians have found significant treatment differences.²² Outcome-based quality of care studies can be misleading.²³ In fact, in a systematic review of the generalist-specialist quality of care literature, studies favoring specialist care were less likely to control for 4 key potential confounders: (1) physician volume or experience, (2) information technology support, (3) care management programs, and (4) practice size and integration into delivery systems.²⁴

If we accept that these generalist-specialist differences are real, what is the explanation? Because those entering primary care residencies have similar scores on standardized examinations as those entering other residencies,²⁵ differences in quality of care provided must have a cause other than differences in intelligence. Most comparison studies are observational and focus on process rather than outcome, and specialists have longer office visits with more time available to perform process measures whereas primary care physicians must prioritize the use of time during encounters. However, primary care physicians may provide poorer process-based, disease-specific quality of care as a consequence of the complexity of the encounter and environment in primary care as opposed to the narrow focus of the specialty setting.

The complexity of health care in the United States has increased dramatically. Not only has there been an explosion in medical knowledge, but the system itself has also grown more complex in terms of its payers,²⁶ guidelines,²⁷ and medications.²⁸ One potential consequence of increasing complexity is the provision of poorer quality of care.²⁸ The purpose of this study was to build on previous work, estimating the relative complexity of patient encounters in general/family practice, cardiology, and psychiatry settings using data from the 2000 National Ambulatory Medical Care Survey (NAMCS), dissecting the sources of complexity within practice.²⁶ We hypothesized that estimates of complexity, particularly the complexity of the input, will be higher in general/family practice than in either cardiology or psychiatry, primarily because of differences in diversity across visits. Differences should be magnified when adjusted for differences in the duration of office visit. Cardiologists and psychiatrists were chosen as comparison groups because a large portion of the generalist-specialist comparison literature involves these specialties.

【 授权许可】

Unknown   

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