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Article Title

Do Patients With Multiple Chronic Conditions Experience the Same Care as Patients With Fewer Chronic Illnesses? Insights From Videos of Primary Care Office Visits

Publication Date

4-30-2015

Keywords

aging, multiple chronic conditions

Abstract

Background/Aims: How do primary care physicians (PCPs) manage multiple chronic conditions (MCC) patients given the financial incentives in their practices?

Methods: Qualitative and quantitative analyses of a convenience sample of 385 video recordings of older patient-PCP conversations in three primary care practice settings — an academic medical center (AMC) with salaried PCPs, a fee-for-service (FFS) managed care group (MCG) and several FFS inner-city solo practices (ICS) — in the Midwest and Southwest. We identified topics –– issues requiring a response from either patient or physician — that emerged during a visit and categorized them according to a coding system. We recorded the time spent on each topic and visit length. To measure the topic’s severity, we mapped the topics to the five top leading causes of disabilities (LCD) identified by the National Center for Health Statistics: pain, cardiovascular diseases, diabetes, lung diseases and mental illnesses. We assessed patient-centeredness by physician’s empathy, warmth and engagement in informed decision-making. Generalized estimation equation (GEE) analyses examined the pattern of time use and patient-centeredness across patients with 0 LCD, 1 LCD or ≥ 2 LCDs (i.e. MCC).

Results: Over 56% (216/385) of visits contained ≥ 2 LCDs. Average length of visits with 0 LCD lasted 13.21 minutes, whereas visits with 1 LCD lasted 16.63 minutes, and averaged 18.93 minutes for ≥ 2 LCDs. MCC visits in the AMC were longer (23.91 minutes), followed by MCG (14.82 minutes) and ICS (12.42 minutes). Within visits, GEE findings suggested if a visit had only 1 LCD, time spent on the LCD was 2.90 minutes. If a visit had ≥ 2 LCDs, time on each LCD was reduced to 2.51 minutes. Compared to FFS PCPs, AMC physicians not only spent more time (2.95 vs. 2.23 minutes/LCD) with MCC patients, their communication also was more patient-centered. Qualitative analyses of MCC visits revealed a sometimes narrow focus on some individual LCDs while overlooking others.

Discussion: MCC patients experienced longer visits, although the increase in number of LCDs is associated with a reduction in the time spent on each LCD within the visit. Salaried AMC physicians not only spent more time with MCC patients, but also were more patient-centered in communication. Payment policies that reward value over volume could facilitate patient-centered care for MCC patients.

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