Intention to discontinue care among primary care patients
Rent the article at a discountRent now
* Final gross prices may vary according to local VAT.Get Access
BACKGROUND: Specific elements of health care process and physician behavior have been shown to influence disenrollment decisions in HMOs, but not in outpatient settings caring for patients with diverse types of insurance coverage.
OBJECTIVE: To examine whether physician behavior and process of care affect patients’ intention to return to their usual health care practice.
DESIGN: Cross-sectional patient survey and medical record review.
SETTING: Eleven academically affiliated primary care medicine practices in the Boston area.
PATIENTS: 2,782 patients with at least one visit in the preceding year.
MEASUREMENT: Unwillingness to return to the usual health care practice.
RESULTS: Of the 2,782 patients interviewed, 160 (5.8%) indicated they would not be willing to return. Two variables correlated significantly with unwillingness to return after adjustment for demographics, health status, health care utilization, satisfaction with physician’s technical skill, site of care, and clustering of patients by provider: dissatisfaction with visit duration (odds ratio [OR], 3.2; 95% confidence interval [CI], 1.4 to 7.4) and patient reports that the physician did not listen to what the patient had to say (OR, 8.8; 95% CI, 2.5 to 30.7). In subgroup analysis, patients who were prescribed medications at their last visit but who did not receive an explanation of the purpose of the medication were more likely to be unwilling to return (OR, 4.9; 95% CI, 1.8 to 13.3).
CONCLUSION: Failure of physicians to acknowledge patient concerns, provide explanations of care, and spend sufficient time with patients may contribute to patients’ decisions to discontinue care at their usual site of care.
- Emanuel EJ, Dubler NN. Preserving the physician-patient relationship in the era of managed care. JAMA. 1995;273:323–9. CrossRef
- Mechanic D, Schlesinger M. The impact of managed care on patients’ trust in medical care and their physicians. JAMA. 1996;275:1693–7. CrossRef
- Zyzanski SJ, Stange KC, Lange D, Flocke SA. Trade-offs in high-volume primary care practice. J Fam Pract. 1998;46:397–402.
- Grumbach K, Osmond D, Vranizan K, Jaffe D, Bindman AB. Primary care physicians’ experience of financial incentives in managed-care systems. N Engl J Med. 1998;339:1516–21. CrossRef
- Hillman AL, Pauly MV, Kerstein JJ. How do financial incentives affect physicians’ clinical decisions and the financial performance of health maintenance organizations? N Engl J Med. 1989;321:86–92. CrossRef
- Kerr EA, Hays RD, Mittman BS, Siu AL, Leake B, Brook RH. Primary care physicians’ satisfaction with quality of care in California capitated medical groups. JAMA. 1997;278:308–12. CrossRef
- Feldman DS, Novack DH, Gracely E. Effects of managed care on physician-patient relationships, quality of care and the ethical practice of medicine: a physician survey. Arch Intern Med. 1998;158:1626–32. CrossRef
- Baker LC, Cantor JC. Physician satisfaction under managed care. Health Affairs. 1993;12(Suppl.):258–70. CrossRef
- Blendon RJ, Knox RA, Brodie M, Benson JM, Chervinsky G. Americans compare managed care, Medicare, and fee for service. J Am Health Policy. 1994;4:42–7.
- Cleary PD, McNeil BJ. Patient satisfaction as an indicator of quality care. Inquiry. 1988;25:25–36.
- Newcomer R, Preston S, Harrington C. Health plan satisfaction and risk of disenrollment among social/HMO and fee-for-service recipients. Inquiry. 1996;33:144–54.
- Mechanic D, Weiss N, Cleary PD. The growth of HMOs: Issues of enrollment and disenrollment. Med Care. 1983;21:338–47. CrossRef
- Joos SK, Hickam DH, Borders LM. Patients’ desires and satisfaction in general medicine clinics. Public Health Rep. 1993;108:751–9.
- Froehlich GW, Welch HG. Meeting walk-in patients’ expectations for testing. Effects on satisfaction. J Gen Intern Med. 1996;11:470–4. CrossRef
- Robbins JA, Bertakis KD, Helms LJ, Azari R, Callahan EJ, Creten DA. The influence of physician practice behaviors on patient satisfaction. Fam Med. 1993;25:17–20.
- Hall JA, Roter DL, Katz NR. Meta-analysis of correlates of provider behavior in medical encounters. Med Care. 1988;26:657–75. CrossRef
- O’Malley AS, Mandelblatt J, Gold K, Cagney KA, Kerner J. Continuity of care and the use of breast and cervical cancer screening services in a multiethnic community. Arch Intern Med. 1997;157:1462–70. CrossRef
- Wasson JH, Sauvigne AE, Mogielnicki RP, et al. Continuity of outpatient medical care in elderly men. A randomized trial. JAMA. 1984;252:2413–7. CrossRef
- Mainous AG, Gill JM. The importance of continuity of care in the likelihood of future hospitalization: Is site of care equivalent to a primary clinician? Am J Public Health. 1998;88:1539–41. CrossRef
- Gill JM, Mainous AG. The role of provider continuity in preventing hospitalizations. Arch Fam Med. 1998;7:352–7. CrossRef
- Hennelly VD, Boxerman SB. Out-of-plan use and disenrollment: Outgrowths of dissatisfaction with a prepaid group plan. Med Care. 1983;21:348–59. CrossRef
- Rubin HR, Gandek B, Rogers WH, Kosinski M, McHorney CA, Ware JE. Patients’ ratings of outpatient visits in different practice settings. Results from the Medical Outcomes Study. JAMA. 1993;270:835–40. CrossRef
- Kaplan SH, Greenfield S, Gandek B, Rogers WH, Ware JE. Characteristics of physicians with participatory decision making styles. Ann Intern Med. 1996;124:497–504.
- vom Eigen KA, Delbanco TL, Phillips RS. Perceptions of quality of care and the decision to leave a practice. Am J Med Qual. 1998;13:181–7. CrossRef
- Mechanic D. Changing medical organization and the erosion of trust. Milbank Quarterly. 1996;74:171–89. CrossRef
- Tarlov AR, Ware JE, Greenfield S, Nelson EC, Perrin E, Zubkoff M. The Medical Outcomes Study. An application of methods for monitoring the results of medical care. JAMA. 1989;262:925–30. CrossRef
- Burton P, Gurrin L, Sly P. Extending the simple linear regression model to account for correlated responses: an introduction to generalized estimating equations and multi-level mixed modeling. Stat Med. 1998;17(11):1261–91. CrossRef
- Laine C, Davidoff F, Lewis CE, et al. Important elements of outpatient care: a comparison of patients’ and physicians’ opinions. Ann Intern Med. 1996;125:640–5.
- Delbanco TL. Enriching the doctor-patient relationship by inviting the patient’s perspective. Ann Intern Med. 1992;116:414–8.
- Kravitz RL, Cope DW, Bhrany V, Leake B. Internal medicine patients’ expectations for care during office visits. J Gen Int Med. 1994;9:75–81. CrossRef
- Levinson W, Stiles WB, Inui TS, Engle R. Physician frustration in communicating with patients. Med Care. 1993;31:285–95. CrossRef
- Gross DA, Zyzanski SJ, Borawski EA, Cebul RD, Stange KC. Patient satisfaction with time spent with their physician. J Fam Pract. 1998;47:133–7.
- Smith CK, Polis E, Hadac RR. Characteristics of the initial medical interview associated with patient satisfaction and understanding. J Fam Pract. 1981;12:283–8.
- Probst JC, Greenhouse DL, Selassie AW. Patient and physician satisfaction with an outpatient care visit. J Fam Pract. 1997;45:418–25.
- Kravitz RL, Callahan EJ, Paterniti D, Antonius D, Dunham M, Lewis CE. Prevalence and sources of patients’ unmet expectations for care. Ann Intern Med. 1996;125:730–7.
- Sherbourne CD, Sturm R, Wells KB. What outcomes matter to patients? J Gen Intern Med. 1999;14:357–63. CrossRef
- Weingarten SR, Stone E, Green A, et al. A study of patient satisfaction and adherence to preventive care practice guidelines. Am J Med. 1995;99:590–6. CrossRef
- Grumbach K, Selby JV, Dmaberg C, et al. Resolving the gatekeeper conundrum. What patients value in primary care and referrals to specialists. JAMA. 1999;282:261–6. CrossRef
- Safran DG, Taira DA, Rogers WH, Kosinski M, Ware JE, Tarlov AR. Linking primary care performance to outcomes of care. J Fam Pract. 1998;47:213–20.
- Wee CC, Phillips RS, Burstin HR, et al. Influence of financial productivity incentives on the use of preventive care. Am J Med. 2001;110:181–7. CrossRef
- Jackson JL, Kroenke K. Difficult patient encounters in the ambulatory clinic: clinical predictors and outcomes. Arch Intern Med. 1999;159:1069–75. CrossRef
- Intention to discontinue care among primary care patients
Journal of General Internal Medicine
Volume 16, Issue 10 , pp 668-674
- Cover Date
- Print ISSN
- Online ISSN
- Additional Links
- physician behavior
- primary care
- continuity of care
- managed care
- Industry Sectors
- Author Affiliations
- 1. Received from the Division of General Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Mass
- 2. the Division of General Medicine and Primary Care, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass
- 3. the Division of General Internal Medicine, San Francisco General Hospital, the Institute for Health Policy Studies, University of California, San Francisco, Calif
- 4. the Agency for Health Care Research and Quality, Rockville, Md