In Managed Care, Primary Care Visits Found Satisfactory

DURHAM, N.C., March 14 -- Even with managed care coverage, patients generally had treatment when visiting a primary care physician's office that met expectations, according to investigators here.

This includes new drugs, tests, or referrals, or a reasonable alternative or a good reason for rejection, reported Sheri A. Keitz, M.D., Ph.D., of Duke and the VA Medical Center, and colleagues.

"Expectations were largely met, and unmet expectations were satisfactorily explained by physicians, with alternatives that were acceptable to the patients 94.7% of the time," the investigators wrote in the March 12 Archives of Internal Medicine.

The findings suggest that despite cost-control pressures built into managed care, physicians usually provide the care that patients want, especially when the patients aren't shy about voicing their wishes and can clearly express them, the authors found.

To get a better handle on what goes inside the examining room, Dr. Keitz and colleagues first approached patients in the waiting rooms of 55 physicians from 20 randomly selected private care practices their were part of a managed care network covering nearly two million patients in North and South Carolina.

Research assistants in waiting rooms consecutively approached patients who were listed on the daily appointment sheets, and asked them 10 screening questions about their expectation for the visit. If they mentioned a desire for a new medication, test, or referral, they were offered the chance to take part in the study.

With the knowledge of both patients and doctors, the assistants set up recorders in the examination room, but were not present during the clinical visit. The patients were interviewed after their visits on site or later on by telephone, and completed the American Board of Internal Medicine Patient Satisfaction Questionnaire and Visit-Specific Questionnaire. The former rates physician performance on humanistic aspects of care, while the latter looks at the quality of the overall visit.

Patients who said that the visit didn't live up to their expectations were called within two weeks and were asked to candidly discuss their concerns.

A total of 256 self-reported expectations were recorded from 200 patient visits. Patients expressed nearly all of their expectation (97.3%) during the visits.

The patients who had expectations expressed them directly 40.6% of the time, and brought up symptoms related to their request 29.7% of the time. In 27% of the visits, the physician first mentioned the subject.

The authors found that at least two-thirds of patients' expectations (66.8%) were met, and for 21.6% of the others the physicians suggested acceptable alternatives.

Patients were more likely to get their expected medications (75.6% of the time) or tests (71.4%) than they were to get a referral (40.8%).

Nearly 90% of the patients of the patients rated their physicians' performance as "excellent" or "very good," 39.3% gave top marks to their doctors on all 10 items on the Patient Satisfaction Questionnaire, and 98.4% said on the post-visit survey that their overall expectations were completely or largely met.

"Trust in physician ratings was generally high, with a median score of 1.7 (Q1=1.4 and Q3=2.1) on a scale from 1 to 5, with 1 representing the most trust," the investigators wrote. "Patients predominantly felt involved in the decision-making process, with 92.2% reporting that their physician 'definitely' or 'probably' would ask the patient for help making a decision between choice of treatments, 81.3% 'very often' or 'often' were given some control over treatment, and 69.3% were asked to take some of the responsibility for treatment."

Patients were uniformly satisfied whether their expectations were met, an alternative was proposed, or the expectations were postponed or left unfulfilled at the visit, the authors added.

Physicians reported that they would not have ordered 62 (44.9%) of 138 requests had the patients not directly asked, and they were uncomfortable filling eight requests (12.9%).

"The results of this study suggest that patient and physician communication choices affect the management of expectations," Dr. Keitz and colleagues wrote in their conclusion. "Understanding how modes of communication affect physician behavior may assist in empowering patients to be effective partners in their own health care. For physicians, learning how to effectively negotiate and respond to patient requests might assist in developing effective paradigms for cost-effective practice that do not negatively affect patient satisfaction."

They noted that the results may not be generalizable to patient-physician encounters in settings other than managed care, and that there may have been a bias toward study participation among patients who were generally satisfied with their physicians and their care in the first place. Recording the visit may also have affected the outcomes, they added.