Article Figures & Data
Figures
- Figure 1.
Participant flowchart.
Tables
Item and Scale Factor Loading Cronbach α Physician satisfaction with aspects of chronic care Regarding your chronically ill older patients, how satisfied are you with the following aspects of care that you and your staff provide (with 6 response options, ranging from “very dissatisfied” to “very satisfied”)? Satisfaction with patient/family communication scale Communicating with patients 0.62 0.90 Communicating with family caregivers 0.84 Educating family caregivers 0.84 Motivating patients to participate in maximizing their health 0.61 Referrals to community resources 0.64 Satisfaction with management of chronic care Coordinating the care received from all providers 0.77 0.93 Monitoring patients’ chronic conditions 0.82 Efficiency of office visits 0.72 Access to evidence-based guidelines for chronic conditions 0.59 Efficiency of practice team 0.67 Availability of clinical information about your patients 0.63 Time spent managing chronically ill patients Regarding your chronically ill older patients, please rate the amount of time that you need to spend (with 5 response options, ranging from “very little” to “just right” to “excessive”). Talking on the telephone with the patients 0.75 Talking on the telephone with family caregivers 0.84 0.73 Communicating with physicians and other healthcare providers 0.51 Knowledge of patients Regarding your chronically ill older patients, please check the one best answer (with 4 response options, ranging from “definitely not” to “definitely”). Knowledge of patients’ personal circumstances Do you know who lives with each of your patients? 0.79 0.58 Would you know if patients had trouble getting or paying for a prescribed medication? 0.52 Knowledge of patients’ clinical characteristics Do you think you understand what problems are most important to the patients you see? 0.82 0.82 Do you think you know each patient’s complete medical history? 0.67 Do you know all the medications that your patients are taking? 0.77 Characteristic Usual Care (n=20) Guided Care (n=18) ρa a Significance of Fisher’s exact test for categorical variables, Wilcoxon rank-sum test for continuous variables. Physician characteristics Age, mean years (SD) 45.8 (8.2) 45.9 (9.8) 0.976 Female, No. (%) 5 (25) 9 (50) 0.179 Race, No. (%) 0.840 White 12 (60) 12 (67) Black 4 (20) 2 (11) Asian 4 (20) 3 (17) Other 0 (0) 1 (6) Panel size, mean (SD), No. 1,430 (440) 1,584 (570) 0.533 Panel aged ≥65 y, mean (SD), No. 23 (12) 23 (11) 0.784 Practice characteristics Insurance types accepted, No. (%) 0.899 Fee for service 2 (10) 2 (11) Mixed 9 (45) 7 (39) Health maintenance organization 9 (45) 9 (50) Ownership, No. (%) 1.000 Not-for-profit 18 (90) 16 (89) For-profit 2 (10) 2 (11) Location, No. (%) 0.193 Urban 13 (65) 7 (39) Suburban 7 (35) 11 (61) Age of practice, mean (SD), y 20.3 (7.4) 18.8 (7.9) 0.731 Annual patient visits, No. (%) 0.963 <40,000 9 (45) 7 (39) 40,000–80,000 2 (10) 2 (11) 80,000–120,000 6 (30) 5 (28) ≥120,000 3 (15) 4 (22) Full-time equivalent personnel in practice, No. (%) 1.000 <30 3 (15) 3 (17) 30–40 9 (45) 7 (39) 40–50 6 (30) 6 (33) ≥50 2 (10) 2 (11) Full-time physicians, mean (SD), No. 9.8 (4.2) 10.8 (3.9) 0.507 Registered nurse-to-physician ratio, mean (SD) 0.6 (0.2) 0.5 (0.3) 0.079 Nurse-to-physician ratio, mean (SD) 0.8 (0.4) 0.6 (0.4) 0.090 Physician assistant-to-physician ratio, mean (SD) 0.1 (0.1) 0.1 (0.1) 0.346 Administrative staff-to-physician ratio, mean (SD) 1.5 (1.4) 1.2 (1.2) 0.792 Use of electronic medical record, No. (%) 18 (90) 16 (89) 0.656 Use of patient registries, No. (%) 11 (55) 14 (78) 0.128 Use of reminders for patients, No. (%) 20 (100) 18 (100) – Use of reminders for physicians, No. (%) 18 (90) 16 (89) 1.000 Use of electronic communication among clinicians, No. (%) 20 (100) 18 (100) – Provision of readily available evidence-based guidelines, No. (%) 18 (90) 16 (89) 1.000 Encouragement of continuing medical education, No. (%) 11 (55) 11 (61) 0.752 Access to on-site social worker, No. (%) 6 (30) 4 (22) 0.719 Access to a case manager, No. (%) 18 (90) 16 (89) 1.000 Patient/caregiver support group, No. (%) 7 (35) 2 (11) 0.130 Financial performance, No. (%) 1.000 Profit/margin 15 (75) 13 (72) Balanced 2 (10) 2 (11) Deficit 3 (15) 3 (17) Proportion of capitated patients, No. (%) 0.576 <30% 9 (45) 9 (50) 30%–45% 5 (25) 2 (11) 100% 6 (30) 7 (39) Use of practice productivity incentives, No. (%) 11 (55) 9 (50) 1.000 Characteristics Completed Baseline Survey and 1-Year Follow-Up Survey (n=38) Completed Baseline Survey Only (n=7) ρa aSignificance of Fisher’s exact test for categorical variables, Wilcoxon rank-sum test for continuous variables. bρ >0.05. Intervention arm, No. (%) Guided Care group 18 (47) 5 (71) 0.414 Control group 20 (53) 2 (29) Physician characteristics Age, mean (SD), y 45.9 (8.9) 45.4 (8.1) 0.974 Female, No. (%) 14 (37) 4 (57) 0.412 Race, No. (%) White 24 (63) 2 (29) 0.166 Black 6 (16) 1 (14) Asian 7 (18) 4 (57) Other 1 (3) 0 (0) Panel size, mean (SD), No. 1,505 (506) 1,233 (231) 0.163 Percentage of panel 65 y and older, mean (SD), % 23 (11) 22 (8) 0.748 Outcomes, mean (SD) Satisfaction with patient/family communication 4.15 (0.73) 3.97 (1.38) 0.813 Satisfaction with management of chronic care 4.37 (0.81) 3.79 (1.45) 0.346 Time spent managing chronically ill patients 3.89 (0.93) 3.67 (0.86) 0.435 Personal knowledge of patients 2.64 (0.63) 2.50 (0.45) 0.413 Clinical knowledge of patients 2.77 (0.61) 2.89 (0.72) 0.861 Knowledge about all the special visits 2.76 (0.75) 2.43 (0.53) 0.246 Helped appointment for referral visit 2.24 (1.05) 3.14 (0.69) 0.031b Written information to patients’ specialists 3.34 (0.99) 3.42 (0.79) 0.957 Useful information received from specialists 3.37 (0.67) 3.29 (0.49) 0.557 - Table 4.
Physicians’ Average Ratings of Chronic Care Processes at Baseline and 1 Year Later
Usual Care Group Guided Care Group Variable Baseline Mean (CI) 1 Year Mean (CI) Baseline Mean (CI) 1 Year Mean (CI) ρa aSignificance of regression coefficient for Guided Care in linear regression models of 1-year scores, adjusting for baseline scores and practice ownership. Satisfaction with patient/family communication 4.25 (3.86–4.64) 3.94 (3.58–4.30) 4.03 (3.72–4.34) 4.40 (3.99–4.81) 0.014 Satisfaction with management of chronic care 4.29 (3.86–4.72) 4.08 (3.70–4.45) 4.46 (4.11–4.81) 4.42 (3.99–4.85) 0.285 Time spent managing chronically ill patients 3.93 (3.55–4.31) 2.85 (2.49–3.21) 3.85 (3.31–4.39) 2.94 (2.58–3.31) 0.601 Knowledge of patients’ personal circumstances 2.60 (2.29 2.92) 2.67 (2.44–2.90) 2.72 (2.39–3.06) 2.78 (2.49–3.07) 0.727 Knowledge of patients’ clinical characteristics 2.70 (2.38–3.02) 2.77 (2.50–3.03) 2.85 (2.59–3.11) 3.17 (2.88–3.46) 0.042 Physician knows about all specialist visits 2.65 (2.24–3.06) 2.65 (2.21–3.09) 2.89 (2.60–3.18) 2.89 (2.44–3.34) 0.732 Someone in office helps patient make appointment for referral visit 2.25 (1.70–2.80) 1.89 (1.3–2.45) 2.22 (1.75–2.70) 2.43 (1.90–2.96) 0.079 Written information is sent to patients’ specialists 3.55 (3.23–3.87) 3.00 (2.40–3.61) 3.11 (2.49–.73) 3.33 (2.85–3.82) 0.148 Useful information is received from specialists 3.35 (3.00–3.70) 3.20 (2.87–3.53) 3.39 (3.08–3.69) 3.50 (3.19–3.81) 0.182 - Table 5.
Effect of Guided Care on Physicians’ Ratings of Chronic Care Processes: Regression Coefficients and Effect Sizes in Linear Regression Models
Variable ICCa Coefficientb (95% CI) Effect Sizec (95% CI) CI=confidence interval, ICC = intraclass correlation. aICCs are not shown if the variance within sites is larger than the variance between sites and the values of ICC become artificially low or negative.25 bRegression coefficient of Guided Care in linear regression models of 1-year scores, adjusting for baseline scores and practice ownership. cCalculated using Hedges’ d as follows: 
.
where n1 and n2 are sample sizes of 2 comparison groups, and
where n1 and n2 are the numbers of sample size in 2 groups and df is the degrees of freedom used for a corresponding t value in a linear model.
95% CI = ES− 1:96se to ES+1:96se; where ES stands for effect size and se is the asymptotic standard error for the effect size:
d ρ <0.05. Satisfaction with patient/family communication 0.06 0.59 (0.13 to 1.06)d 0.87 (0.21 to 1.54) Satisfaction with management of chronic care 0.25 0.23 (−0.20 to 0.66) 0.37 (−0.28 to 1.01) Time spent managing chronically ill patients – 0.12 (−0.35 to 0.60) 0.18 (−0.46 to 0.82) Knowledge of patients’ personal circumstances – 0.05 (−0.22 to 0.31) 0.12 (−0.52 to 0.76) Knowledge of patients clinical characteristics 0.33 0.32 (0.01 to 0.63)* 0.71 (0.05 to 1.37) Knowledge about all the special visits 0.37 0.07 (−0.37 to 0.52) 0.12 (−0.52 to 0.76) Helped appointment for referral visit – 0.57 (−0.07 to 1.20) 0.61 (−0.04 to 1.26) Written information to patients’ specialists 0.14 0.54 (−0.20 to 1.29) 0.50 (−0.15 to 1.15) Useful information received from specialists 0.20 0.27 (−0.13 to 0.68) 0.46 (−0.19 to 1.10)
The Article in Brief
Physician Satisfaction With Chronic Care Processes: A Cluster-Randomized Trial of Guided Care.
Jill A. Marsteller , and colleagues
Background In Guided Care, a primary care practice team (including a registered nurse, 2 to 5 doctors, and office staff) provide enhanced care for chronically ill older patients. This study examined the effects of Guided Care on doctors' experiences and satisfaction with specific processes of caring for chronically ill older patients.
What This Study Found Guided Care physicians are significantly more satisfied than other doctors with their patient/family communication and their knowledge of their patients� clinical conditions. Guided Care did not have significant effects on doctors� satisfaction with management of chronic care, knowledge of patients� personal circumstances, or on their ratings of the practice�s care coordination activities.
Implications
- Guided Care can address chronically ill older adults� needs and improve doctors� satisfaction with some processes of care and knowledge of their patients. This may be particularly important as the number of primary care doctors decreases and the number of older adults continues to grow.
Annals Journal Club:
Jul/Aug 2010
Guided Care
The Annals of Family Medicine encourages readers to develop a learning community of those seeking to improve health care and health through enhanced primary care. You can participate by conducting a RADICAL journal club and sharing the results of your discussions in the Annals online discussion for the featured articles. RADICAL is an acronym for Read, Ask, Discuss, Inquire, Collaborate, Act, and Learn. The word radical also indicates the need to engage diverse participants in thinking critically about important issues affecting primary care and then acting on those discussions.1How it Works
In each issue, the Annals selects an article or articles and provides discussion tips and questions. We encourage you to take a RADICAL approach to these materials and to post a summary of your conversation in our online discussion. (Open the article online and click on "TRACK Comments: Submit a response.") You can find discussion questions and more information online at: http://www.AnnFamMed.org/AJC/.
CURRENT SELECTION
Article for Discussion
- Marsteller JA, Hsu YJ, Reider L, et al. Physician satisfaction with chronic care processes: a cluster-randomized trial of Guided Care. Ann Fam Med. 2010; 8(4):308-315.
Discussion Tips
This article provides an opportunity to consider some of the effects and possibilities of an emerging collaborative model of care for complex patients.Discussion Questions
- What question(s) are addressed by this article?
- Why is this study needed beyond previous research on this topic?
- How strong is the study design for answering the question?
- To what degree can the findings be accounted for by:
- How physicians and their patients were selected, excluded, or lost to follow-up?
- How the main variables were measured?
- Confounding (false attribution of causality because 2 variables discovered to be associated actually are associated with a third factor)?
- Chance?
- Does the analysis accounting for the clustered nature of the data (patients nested within physician) increase your confidence in the findings? ∗
- What are the main study findings?
- How comparable is the study sample to similar patients in your practice? What is your judgment about the transportability of the findings?
- How might this study change your practice?
- How does the concept of Guided Care fit with emerging models of the patient-centered medical home (http://www.pcpcc.net)?
- Would the availability of Guided Care (www.guidedcare.org) make you more interested in managing complex older patients in your practice?
- If Guided Care proves to be a robust model of care, what further work would need to be done to make it a sustainable part of health care in your country?
- What important researchable questions remain?
∗ Hint: The answer is yes. See: Zyzanski SJ, Flocke SA, Dickinson LM. On the nature and analysis of clustered data. Ann Fam Med. 2004;2(3):199-200. http://www.annfammed.org/cgi/content/full/2/3/199.References
- Stange KC, Miller WL, McLellan LA, et al. Annals journal club: It�s time to get RADICAL. Ann Fam Med. 2006;4(3):196-197. http://annfammed.org/cgi/content/full/4/3/196.
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