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METHODS: In a cross-sectional study, 170 volunteer primary care clinicians in 50 practices in the Ambulatory Sentinel Practice Network reported all occurrences of care of a secondary patient during 1 week of practice. These clinicians reported the characteristics of the primary patient and the secondary patient and the content of care provided to the secondary patient. Content of care was placed in 6 categories (advice, providing a prescription, assessment or explanation of symptoms, follow-up of a previous episode of care, making or authorizing a referral, and general discussion of a health condition).
RESULTS: Physicians reported providing care to secondary patients during 6% of their office visits. This care involved more than one category of service for the majority of visits involving care of a secondary patient. Advice was provided during more than half the visits. A prescription, assessment or explanation of symptoms, or a general discussion of condition were provided during approximately 30% of the secondary care visits. Secondary care was judged to have substituted for a separate visit 60% of the time, added an average of 5 minutes to the visit, and yielded no reimbursement for 95% of visits.
CONCLUSIONS: Care of a secondary patient reflects the provision of potentially intensive and complex services that require additional time and are largely not reimbursed or recognized by current measures of primary care. This provision of secondary care may facilitate access to care and represent an added value provided by family physicians.
The family as the unit of care has been a philosophical underpinning of family practice since its inception.1-6 It is common for individual family members to see the same physician and for a family member to be present during a patient’s visit.7-10 Flocke and colleagues11 used direct observation to identify the frequency of care of a secondary patient. They defined a secondary patient as a family member other than the identified patient for an outpatient visit and found that care was provided to a second family member during 18% of the visits. Knishkowry and coworkers12 used self-report by a group of Israeli family physicians to identify a 12% frequency of encounters where 1 or more visitors were simultaneously present. Although Flocke and colleagues focused on the assessment of the effects of these encounters on the primary patient and Knishkowry and coworkers described the number and characteristics of the visitors, neither set of authors described the actual content of care provided to the secondary patient. Our study was designed to describe the profile of services provided to secondary patients during visits to family physicians.
Methods
Sample Selection
Our study was conducted in the Ambulatory Sentinel Practice Network (ASPN), a network of 752 community-based primary care clinicians established in 1982 to conduct practice-based research.13 ASPN’s 122 practices in 34 states and 6 Canadian provinces have been shown to serve a patient population similar to the population of the United States.14 In addition, ASPN clinicians demonstrate practice patterns similar to those reported in the National Ambulatory Medical Survey,15 a national probability sample of visits to office-based physicians in the United States.
All ASPN clinicians were invited to participate in the study by a mailing that briefly described the study and its requirements. A total of 170 clinicians (23% of the total) from 50 member practices (41%) volunteered and completed the data collection.
Study Variables
A secondary patient was defined as another individual (a family member or friend of the primary patient who was either present or absent and was not scheduled for the visit) to whom the clinician offered a discernible service. The primary patient was the patient in the office who registered or signed in for the visit.
The clinician made the determination of whether a discernible service was provided to a secondary patient and reported the type of service using categories that included advice, providing a prescription, assessment or explanation of symptoms, follow-up on previous care, referral to another provider, general discussion of the secondary patient’s condition, and other. More than one service could be checked for a given visit. The categories were developed through input from ASPN clinicians at the network’s annual meeting and through subsequent discussion on the ASPN electronic mailing list.
Participating clinicians reported whether it was the primary patient’s first visit to the practice, who initiated the discussion about the secondary patient, whether the secondary patient was present, the estimated time required to discuss the secondary patient, whether the billing code reflected additional care, and an estimate of whether the care provided to the secondary patient could have substituted for a separate visit. The clinician also reported the age and sex of the primary and secondary patients and their relationship (spouse, parent, son or daughter, sibling, other relative, friend).
Data Collection and Analysis
The clinicians who agreed to participate in the study were sent protocol instructions and study materials. They were asked to complete data collection for each patient visit in which care was provided to a secondary patient during a 1-week period. They also reported the total number of all patient visits during the study period.
The data forms were sent to the ASPN central office where they were manually checked for completeness and key entered. The data reported by the clinicians were merged with information on the characteristics of the clinician (age, sex, years in practice) and practice characteristics (rural, urban, suburban) obtained from the ASPN member database.
Descriptive statistics are reported for primary patients, secondary patients, visits, and clinicians. We used chi-square tests for comparisons involving categorical variables and Student t tests to compare means for continuous variables. Significance was reported at P <.05.
Results
The 170 clinicians in 50 ASPN practices who participated in the study reported a total of 6957 patient visits during the 1-week reporting period. Ninety-five of the clinicians (56%) reported 1 or more instances of providing secondary care, yielding a total of 422 (6.1%) visits involving secondary care. Seventy-five clinicians reported no secondary care. The secondary encounter was most often initiated by the primary patient (55%) and least often by the clinician (15%). Secondary patents were present in the office 39% of the time and initiated the secondary care during 30% of the visits.
Clinicians estimated that the secondary care required an average of 4.9 minutes to deliver (range=1-60 minutes). They also reported that 64% of the secondary encounters were likely to have substituted for a separate office visit, while additional billing for the care was reported in only 5.2% of secondary encounters.
Categories of Service to the Secondary Patient
Advice was the discernable service provided in more than half the visits Table 1. Approximately 30% were accounted for equally by prescription, assessment or explanation of symptoms, and general discussion of condition. In addition, advice was also the most frequent service when the secondary patient encounter was judged by the clinician to have substituted for a separate office visit. In fact, advice was the most common in almost every secondary patient category, except secondary patients who were aged 65 years or older, where follow-up of a previous problem was the service category most likely to occur (data not shown).
Finally, certain services were more likely to be initiated by clinicians than patients Table 1. Follow-up and general discussion of a condition were associated with clinician-initiated secondary care, while advice, assessment or explanation of symptoms, and prescriptions were associated with patient-initiated secondary care.
Characteristics Associated with Secondary Care
There were few differences between clinicians who reported secondary care and those who did not. Physicians reporting secondary care were older (P <.05) and more likely to practice in a rural area (P <.05). Clinician sex and years in practice were not remarkable.
Table 2 shows the characteristics of primary and secondary patients. There were a greater percentage of women than men in the primary patient group (64%). The secondary patient was most often a spouse, parent, or child of the primary patient. Eighty-seven percent of the secondary patients were enrolled as patients in the practice.
Discussion
ASPN clinicians reported providing secondary care during approximately 6% of primary care visits and rarely billed for the service. Secondary care was provided primarily in the form of advice to another family member. An episode with a secondary patient was reported to take an average of 5 minutes and to substitute for a visit more than 60% of the time.
This is the first study to examine the content of care given to a secondary patient in community primary care practices. Although arranging a referral, dispensing a prescription (perhaps a renewal), or providing follow-up care might not be unexpected, ASPN clinicians reported more instances of the provision of more time-intensive and complex services, such as advice, assessment or explanation of symptoms, and general discussion of condition. The fact that clinicians reported this secondary care could substitute for an actual office visit 60% of the time further suggests some complexity of the service provided.
The observation that certain services were more likely associated with clinician—rather than patient-initiated—secondary care might relate to how comfortable a clinician was with a particular service. However, the strength of the association for follow-up of a previous episode of care supports the Institute of Medicine definition of primary care as continuous and accountable.16
A limitation of our study is the reliance on physician self-report, which might vary from the report of the patient or an objective observer. The lower frequency of secondary care than reported in the direct observational study by Flocke and colleagues11 is likely due to the lower sensitivity of physician self-report versus direct observation of service delivery.17-19
Although our study does not provide data to identify the reasons that secondary care was provided, it is interesting to speculate that access to care might be involved. Access issues related to the clinician or practice might include the ease of scheduling a visit or phone contact.20 Access issues related to the patient might include transportation, work responsibilities, or child or elder care.20 For example, when the secondary patient was aged 65 years or older, follow-up was the service more likely to occur. Perhaps this represents an accommodation to this age group, thereby possibly obviating the arrangement of transportation for another visit. Transportation, or the lack thereof, might explain why secondary care occurred more often in rural settings. The finding that secondary care tended to be provided more often by older clinicians might be explained by their more comprehensive knowledge of the patient and family. Although the proportion of women was higher for both primary and secondary patients, the finding that the secondary patient was less likely to be a woman is consistent with previous research demonstrating the central role of women in accessing medical care for the family.21,22
Future research should examine the reasons why secondary care is provided, from the perspectives of the physician and primary and secondary patients. In addition, the effects of other factors on the frequency and content of secondary care, such as health insurance, employment, access to care, and family structure must be elucidated. Such studies would provide useful information on the extent to which secondary care is an expression of barriers to access of care or an added value of family practice responding rationally to competing opportunities.23,24 Also, studies need to assess whether the quality of care including the clinical outcomes, patient satisfaction, and cost of care for both primary and secondary patients is affected by the substitution of secondary care for a separate visit.
Conclusions
A physician’s care of a secondary patient includes the provision of potentially time-consuming and complex services that are largely not reimbursed or recognized by current measures of primary care. This provision of secondary care seems to facilitate access to care and represents an added value provided by family physicians.
Related Resources
- American Academy of Family Physicians www.aafp.org
- Center for Research in Family Practice and Primary Care http://mediswww.cwru.edu/dept/crfppc
1. Medalie JH, Zyzanski SJ, Langa DM, Stange KC. The family in family practice: is it a reality? J Fam Pract 1998;46:390-96.
2. Curry HB. The family as our patient. J Fam Pract 1977;4:757-58.
3. Bauman MH, Grace NT. Family process and family practice. J Fam Pract 1977;4:1135-37.
4. Geyman JP. The family as the object of care in family practice. J Fam Pract 1977;5:571-75.
5. Rakel R. Principles of family medicine. Philadelphia, Pa: WB Saunders; 1977.
6. Schmidt DD. The family as the unit of medical care. J Fam Pract 1978;7:303-13.
7. Ransom D. The evolution from an individual to a family approach. In: Henads SG, ed. Principles of family systems in family medicine. New York, NY: Brunner-Mazel; 1985.
8. Chrstie-Seely J. Working with families in primary care: a systems approach to health and illness. New York, NY: Praeger Press; 1984.
9. Bothello RJ, Lue B-H, Fiscella K. Family involvement in routine health care. J Fam Pract 1996;42:572-76.
10. Rogers J, Holloway R. Family escorts of clinic patients. J Fam Pract 1997;44:213.-
11. Flocke S, Goodwin M, Stange K. The effect of a secondary patient on the family practice visit. J Fam Pract 1998;46:429-34.
12. Knishkowy B, Furst A, Fassberg Y, Anor E, Matthews S, Paz Y. Multiple family member visits to family physicians: terminology, classification, and implications. J Fam Pract 1991;32:57-63.
13. Green, LA, Wood M, Becker LA, et al. The ambulatory sentinel practice network: purpose, methods, and policies. J Fam Pract 1984;18:275-80.
14. Green LA, Miller RS, Reed FM, Iverson DC, Barley DE. How representative of typical practice are practice-based research networks? A report from the Ambulatory Sentinel Practice Network (ASPN). Arch Fam Med 1993;2:939-49.
15. Nutting PA, Baier M, Werner JF, Cutter G, Reed FM, Orzano AJ. Practice patterns of family physicians in practice-based research networks: a report from ASPN. J Am Board Fam Pract 1999;12:278-84.
16. Institute of Medicine Donaldson YK, Lohr KN, Vanselow NA, eds. Primary care: America’s health in a new era. Washington, DC: National Academy Press; 1996.
17. Green LA. How can family practice and primary care practice-based research networks contribute to medical effectiveness research? In: Hibbard H, Nutting PA, Grady ML. Primary care research: theory and methods. Rockville, Md: Publisher; 1991.
18. Green LA, Becker LA, Freeman WL, Elliott E, Iverson DC, Reed FM. Spontaneous abortion in primary care: a report from ASPN. J Am Board Fam Pract 1988;1:15-23.
19. Green LA, Reed FM, Miller RS, Iverson DC. Verification of data reported by practices for a study of spontaneous abortion: a report from ASPN. Fam Med 1988;20:189-91.
20. Aday, LA, Fleming GV, Andersen R. Access to medical care. Chicago, Ill: Pluribus Press; 1984.
21. Norcross WA, Ramirez C, Palinkas LA. The influence of women on the health care-seeking behavior of men. J Fam Pract 1996;43:475-80.
22. Lewis CE, Lewis MA. The potential impact of sexual equality on health. N Engl J Med 1977;297:863.-
23. Jaen CR, Stange KC, Nutting PA. The competing demands of primary care: a model for the delivery of clinical preventive services. J Fam Pract 1994;38:166-71.
24. Stange KC, Zyzanski SJ, Jaen CR, et al. Illuminating the ‘black box’: a description of 4454 patient visits to 138 family physicians. J Fam Pract 1998;46:377-89.
METHODS: In a cross-sectional study, 170 volunteer primary care clinicians in 50 practices in the Ambulatory Sentinel Practice Network reported all occurrences of care of a secondary patient during 1 week of practice. These clinicians reported the characteristics of the primary patient and the secondary patient and the content of care provided to the secondary patient. Content of care was placed in 6 categories (advice, providing a prescription, assessment or explanation of symptoms, follow-up of a previous episode of care, making or authorizing a referral, and general discussion of a health condition).
RESULTS: Physicians reported providing care to secondary patients during 6% of their office visits. This care involved more than one category of service for the majority of visits involving care of a secondary patient. Advice was provided during more than half the visits. A prescription, assessment or explanation of symptoms, or a general discussion of condition were provided during approximately 30% of the secondary care visits. Secondary care was judged to have substituted for a separate visit 60% of the time, added an average of 5 minutes to the visit, and yielded no reimbursement for 95% of visits.
CONCLUSIONS: Care of a secondary patient reflects the provision of potentially intensive and complex services that require additional time and are largely not reimbursed or recognized by current measures of primary care. This provision of secondary care may facilitate access to care and represent an added value provided by family physicians.
The family as the unit of care has been a philosophical underpinning of family practice since its inception.1-6 It is common for individual family members to see the same physician and for a family member to be present during a patient’s visit.7-10 Flocke and colleagues11 used direct observation to identify the frequency of care of a secondary patient. They defined a secondary patient as a family member other than the identified patient for an outpatient visit and found that care was provided to a second family member during 18% of the visits. Knishkowry and coworkers12 used self-report by a group of Israeli family physicians to identify a 12% frequency of encounters where 1 or more visitors were simultaneously present. Although Flocke and colleagues focused on the assessment of the effects of these encounters on the primary patient and Knishkowry and coworkers described the number and characteristics of the visitors, neither set of authors described the actual content of care provided to the secondary patient. Our study was designed to describe the profile of services provided to secondary patients during visits to family physicians.
Methods
Sample Selection
Our study was conducted in the Ambulatory Sentinel Practice Network (ASPN), a network of 752 community-based primary care clinicians established in 1982 to conduct practice-based research.13 ASPN’s 122 practices in 34 states and 6 Canadian provinces have been shown to serve a patient population similar to the population of the United States.14 In addition, ASPN clinicians demonstrate practice patterns similar to those reported in the National Ambulatory Medical Survey,15 a national probability sample of visits to office-based physicians in the United States.
All ASPN clinicians were invited to participate in the study by a mailing that briefly described the study and its requirements. A total of 170 clinicians (23% of the total) from 50 member practices (41%) volunteered and completed the data collection.
Study Variables
A secondary patient was defined as another individual (a family member or friend of the primary patient who was either present or absent and was not scheduled for the visit) to whom the clinician offered a discernible service. The primary patient was the patient in the office who registered or signed in for the visit.
The clinician made the determination of whether a discernible service was provided to a secondary patient and reported the type of service using categories that included advice, providing a prescription, assessment or explanation of symptoms, follow-up on previous care, referral to another provider, general discussion of the secondary patient’s condition, and other. More than one service could be checked for a given visit. The categories were developed through input from ASPN clinicians at the network’s annual meeting and through subsequent discussion on the ASPN electronic mailing list.
Participating clinicians reported whether it was the primary patient’s first visit to the practice, who initiated the discussion about the secondary patient, whether the secondary patient was present, the estimated time required to discuss the secondary patient, whether the billing code reflected additional care, and an estimate of whether the care provided to the secondary patient could have substituted for a separate visit. The clinician also reported the age and sex of the primary and secondary patients and their relationship (spouse, parent, son or daughter, sibling, other relative, friend).
Data Collection and Analysis
The clinicians who agreed to participate in the study were sent protocol instructions and study materials. They were asked to complete data collection for each patient visit in which care was provided to a secondary patient during a 1-week period. They also reported the total number of all patient visits during the study period.
The data forms were sent to the ASPN central office where they were manually checked for completeness and key entered. The data reported by the clinicians were merged with information on the characteristics of the clinician (age, sex, years in practice) and practice characteristics (rural, urban, suburban) obtained from the ASPN member database.
Descriptive statistics are reported for primary patients, secondary patients, visits, and clinicians. We used chi-square tests for comparisons involving categorical variables and Student t tests to compare means for continuous variables. Significance was reported at P <.05.
Results
The 170 clinicians in 50 ASPN practices who participated in the study reported a total of 6957 patient visits during the 1-week reporting period. Ninety-five of the clinicians (56%) reported 1 or more instances of providing secondary care, yielding a total of 422 (6.1%) visits involving secondary care. Seventy-five clinicians reported no secondary care. The secondary encounter was most often initiated by the primary patient (55%) and least often by the clinician (15%). Secondary patents were present in the office 39% of the time and initiated the secondary care during 30% of the visits.
Clinicians estimated that the secondary care required an average of 4.9 minutes to deliver (range=1-60 minutes). They also reported that 64% of the secondary encounters were likely to have substituted for a separate office visit, while additional billing for the care was reported in only 5.2% of secondary encounters.
Categories of Service to the Secondary Patient
Advice was the discernable service provided in more than half the visits Table 1. Approximately 30% were accounted for equally by prescription, assessment or explanation of symptoms, and general discussion of condition. In addition, advice was also the most frequent service when the secondary patient encounter was judged by the clinician to have substituted for a separate office visit. In fact, advice was the most common in almost every secondary patient category, except secondary patients who were aged 65 years or older, where follow-up of a previous problem was the service category most likely to occur (data not shown).
Finally, certain services were more likely to be initiated by clinicians than patients Table 1. Follow-up and general discussion of a condition were associated with clinician-initiated secondary care, while advice, assessment or explanation of symptoms, and prescriptions were associated with patient-initiated secondary care.
Characteristics Associated with Secondary Care
There were few differences between clinicians who reported secondary care and those who did not. Physicians reporting secondary care were older (P <.05) and more likely to practice in a rural area (P <.05). Clinician sex and years in practice were not remarkable.
Table 2 shows the characteristics of primary and secondary patients. There were a greater percentage of women than men in the primary patient group (64%). The secondary patient was most often a spouse, parent, or child of the primary patient. Eighty-seven percent of the secondary patients were enrolled as patients in the practice.
Discussion
ASPN clinicians reported providing secondary care during approximately 6% of primary care visits and rarely billed for the service. Secondary care was provided primarily in the form of advice to another family member. An episode with a secondary patient was reported to take an average of 5 minutes and to substitute for a visit more than 60% of the time.
This is the first study to examine the content of care given to a secondary patient in community primary care practices. Although arranging a referral, dispensing a prescription (perhaps a renewal), or providing follow-up care might not be unexpected, ASPN clinicians reported more instances of the provision of more time-intensive and complex services, such as advice, assessment or explanation of symptoms, and general discussion of condition. The fact that clinicians reported this secondary care could substitute for an actual office visit 60% of the time further suggests some complexity of the service provided.
The observation that certain services were more likely associated with clinician—rather than patient-initiated—secondary care might relate to how comfortable a clinician was with a particular service. However, the strength of the association for follow-up of a previous episode of care supports the Institute of Medicine definition of primary care as continuous and accountable.16
A limitation of our study is the reliance on physician self-report, which might vary from the report of the patient or an objective observer. The lower frequency of secondary care than reported in the direct observational study by Flocke and colleagues11 is likely due to the lower sensitivity of physician self-report versus direct observation of service delivery.17-19
Although our study does not provide data to identify the reasons that secondary care was provided, it is interesting to speculate that access to care might be involved. Access issues related to the clinician or practice might include the ease of scheduling a visit or phone contact.20 Access issues related to the patient might include transportation, work responsibilities, or child or elder care.20 For example, when the secondary patient was aged 65 years or older, follow-up was the service more likely to occur. Perhaps this represents an accommodation to this age group, thereby possibly obviating the arrangement of transportation for another visit. Transportation, or the lack thereof, might explain why secondary care occurred more often in rural settings. The finding that secondary care tended to be provided more often by older clinicians might be explained by their more comprehensive knowledge of the patient and family. Although the proportion of women was higher for both primary and secondary patients, the finding that the secondary patient was less likely to be a woman is consistent with previous research demonstrating the central role of women in accessing medical care for the family.21,22
Future research should examine the reasons why secondary care is provided, from the perspectives of the physician and primary and secondary patients. In addition, the effects of other factors on the frequency and content of secondary care, such as health insurance, employment, access to care, and family structure must be elucidated. Such studies would provide useful information on the extent to which secondary care is an expression of barriers to access of care or an added value of family practice responding rationally to competing opportunities.23,24 Also, studies need to assess whether the quality of care including the clinical outcomes, patient satisfaction, and cost of care for both primary and secondary patients is affected by the substitution of secondary care for a separate visit.
Conclusions
A physician’s care of a secondary patient includes the provision of potentially time-consuming and complex services that are largely not reimbursed or recognized by current measures of primary care. This provision of secondary care seems to facilitate access to care and represents an added value provided by family physicians.
Related Resources
- American Academy of Family Physicians www.aafp.org
- Center for Research in Family Practice and Primary Care http://mediswww.cwru.edu/dept/crfppc
METHODS: In a cross-sectional study, 170 volunteer primary care clinicians in 50 practices in the Ambulatory Sentinel Practice Network reported all occurrences of care of a secondary patient during 1 week of practice. These clinicians reported the characteristics of the primary patient and the secondary patient and the content of care provided to the secondary patient. Content of care was placed in 6 categories (advice, providing a prescription, assessment or explanation of symptoms, follow-up of a previous episode of care, making or authorizing a referral, and general discussion of a health condition).
RESULTS: Physicians reported providing care to secondary patients during 6% of their office visits. This care involved more than one category of service for the majority of visits involving care of a secondary patient. Advice was provided during more than half the visits. A prescription, assessment or explanation of symptoms, or a general discussion of condition were provided during approximately 30% of the secondary care visits. Secondary care was judged to have substituted for a separate visit 60% of the time, added an average of 5 minutes to the visit, and yielded no reimbursement for 95% of visits.
CONCLUSIONS: Care of a secondary patient reflects the provision of potentially intensive and complex services that require additional time and are largely not reimbursed or recognized by current measures of primary care. This provision of secondary care may facilitate access to care and represent an added value provided by family physicians.
The family as the unit of care has been a philosophical underpinning of family practice since its inception.1-6 It is common for individual family members to see the same physician and for a family member to be present during a patient’s visit.7-10 Flocke and colleagues11 used direct observation to identify the frequency of care of a secondary patient. They defined a secondary patient as a family member other than the identified patient for an outpatient visit and found that care was provided to a second family member during 18% of the visits. Knishkowry and coworkers12 used self-report by a group of Israeli family physicians to identify a 12% frequency of encounters where 1 or more visitors were simultaneously present. Although Flocke and colleagues focused on the assessment of the effects of these encounters on the primary patient and Knishkowry and coworkers described the number and characteristics of the visitors, neither set of authors described the actual content of care provided to the secondary patient. Our study was designed to describe the profile of services provided to secondary patients during visits to family physicians.
Methods
Sample Selection
Our study was conducted in the Ambulatory Sentinel Practice Network (ASPN), a network of 752 community-based primary care clinicians established in 1982 to conduct practice-based research.13 ASPN’s 122 practices in 34 states and 6 Canadian provinces have been shown to serve a patient population similar to the population of the United States.14 In addition, ASPN clinicians demonstrate practice patterns similar to those reported in the National Ambulatory Medical Survey,15 a national probability sample of visits to office-based physicians in the United States.
All ASPN clinicians were invited to participate in the study by a mailing that briefly described the study and its requirements. A total of 170 clinicians (23% of the total) from 50 member practices (41%) volunteered and completed the data collection.
Study Variables
A secondary patient was defined as another individual (a family member or friend of the primary patient who was either present or absent and was not scheduled for the visit) to whom the clinician offered a discernible service. The primary patient was the patient in the office who registered or signed in for the visit.
The clinician made the determination of whether a discernible service was provided to a secondary patient and reported the type of service using categories that included advice, providing a prescription, assessment or explanation of symptoms, follow-up on previous care, referral to another provider, general discussion of the secondary patient’s condition, and other. More than one service could be checked for a given visit. The categories were developed through input from ASPN clinicians at the network’s annual meeting and through subsequent discussion on the ASPN electronic mailing list.
Participating clinicians reported whether it was the primary patient’s first visit to the practice, who initiated the discussion about the secondary patient, whether the secondary patient was present, the estimated time required to discuss the secondary patient, whether the billing code reflected additional care, and an estimate of whether the care provided to the secondary patient could have substituted for a separate visit. The clinician also reported the age and sex of the primary and secondary patients and their relationship (spouse, parent, son or daughter, sibling, other relative, friend).
Data Collection and Analysis
The clinicians who agreed to participate in the study were sent protocol instructions and study materials. They were asked to complete data collection for each patient visit in which care was provided to a secondary patient during a 1-week period. They also reported the total number of all patient visits during the study period.
The data forms were sent to the ASPN central office where they were manually checked for completeness and key entered. The data reported by the clinicians were merged with information on the characteristics of the clinician (age, sex, years in practice) and practice characteristics (rural, urban, suburban) obtained from the ASPN member database.
Descriptive statistics are reported for primary patients, secondary patients, visits, and clinicians. We used chi-square tests for comparisons involving categorical variables and Student t tests to compare means for continuous variables. Significance was reported at P <.05.
Results
The 170 clinicians in 50 ASPN practices who participated in the study reported a total of 6957 patient visits during the 1-week reporting period. Ninety-five of the clinicians (56%) reported 1 or more instances of providing secondary care, yielding a total of 422 (6.1%) visits involving secondary care. Seventy-five clinicians reported no secondary care. The secondary encounter was most often initiated by the primary patient (55%) and least often by the clinician (15%). Secondary patents were present in the office 39% of the time and initiated the secondary care during 30% of the visits.
Clinicians estimated that the secondary care required an average of 4.9 minutes to deliver (range=1-60 minutes). They also reported that 64% of the secondary encounters were likely to have substituted for a separate office visit, while additional billing for the care was reported in only 5.2% of secondary encounters.
Categories of Service to the Secondary Patient
Advice was the discernable service provided in more than half the visits Table 1. Approximately 30% were accounted for equally by prescription, assessment or explanation of symptoms, and general discussion of condition. In addition, advice was also the most frequent service when the secondary patient encounter was judged by the clinician to have substituted for a separate office visit. In fact, advice was the most common in almost every secondary patient category, except secondary patients who were aged 65 years or older, where follow-up of a previous problem was the service category most likely to occur (data not shown).
Finally, certain services were more likely to be initiated by clinicians than patients Table 1. Follow-up and general discussion of a condition were associated with clinician-initiated secondary care, while advice, assessment or explanation of symptoms, and prescriptions were associated with patient-initiated secondary care.
Characteristics Associated with Secondary Care
There were few differences between clinicians who reported secondary care and those who did not. Physicians reporting secondary care were older (P <.05) and more likely to practice in a rural area (P <.05). Clinician sex and years in practice were not remarkable.
Table 2 shows the characteristics of primary and secondary patients. There were a greater percentage of women than men in the primary patient group (64%). The secondary patient was most often a spouse, parent, or child of the primary patient. Eighty-seven percent of the secondary patients were enrolled as patients in the practice.
Discussion
ASPN clinicians reported providing secondary care during approximately 6% of primary care visits and rarely billed for the service. Secondary care was provided primarily in the form of advice to another family member. An episode with a secondary patient was reported to take an average of 5 minutes and to substitute for a visit more than 60% of the time.
This is the first study to examine the content of care given to a secondary patient in community primary care practices. Although arranging a referral, dispensing a prescription (perhaps a renewal), or providing follow-up care might not be unexpected, ASPN clinicians reported more instances of the provision of more time-intensive and complex services, such as advice, assessment or explanation of symptoms, and general discussion of condition. The fact that clinicians reported this secondary care could substitute for an actual office visit 60% of the time further suggests some complexity of the service provided.
The observation that certain services were more likely associated with clinician—rather than patient-initiated—secondary care might relate to how comfortable a clinician was with a particular service. However, the strength of the association for follow-up of a previous episode of care supports the Institute of Medicine definition of primary care as continuous and accountable.16
A limitation of our study is the reliance on physician self-report, which might vary from the report of the patient or an objective observer. The lower frequency of secondary care than reported in the direct observational study by Flocke and colleagues11 is likely due to the lower sensitivity of physician self-report versus direct observation of service delivery.17-19
Although our study does not provide data to identify the reasons that secondary care was provided, it is interesting to speculate that access to care might be involved. Access issues related to the clinician or practice might include the ease of scheduling a visit or phone contact.20 Access issues related to the patient might include transportation, work responsibilities, or child or elder care.20 For example, when the secondary patient was aged 65 years or older, follow-up was the service more likely to occur. Perhaps this represents an accommodation to this age group, thereby possibly obviating the arrangement of transportation for another visit. Transportation, or the lack thereof, might explain why secondary care occurred more often in rural settings. The finding that secondary care tended to be provided more often by older clinicians might be explained by their more comprehensive knowledge of the patient and family. Although the proportion of women was higher for both primary and secondary patients, the finding that the secondary patient was less likely to be a woman is consistent with previous research demonstrating the central role of women in accessing medical care for the family.21,22
Future research should examine the reasons why secondary care is provided, from the perspectives of the physician and primary and secondary patients. In addition, the effects of other factors on the frequency and content of secondary care, such as health insurance, employment, access to care, and family structure must be elucidated. Such studies would provide useful information on the extent to which secondary care is an expression of barriers to access of care or an added value of family practice responding rationally to competing opportunities.23,24 Also, studies need to assess whether the quality of care including the clinical outcomes, patient satisfaction, and cost of care for both primary and secondary patients is affected by the substitution of secondary care for a separate visit.
Conclusions
A physician’s care of a secondary patient includes the provision of potentially time-consuming and complex services that are largely not reimbursed or recognized by current measures of primary care. This provision of secondary care seems to facilitate access to care and represents an added value provided by family physicians.
Related Resources
- American Academy of Family Physicians www.aafp.org
- Center for Research in Family Practice and Primary Care http://mediswww.cwru.edu/dept/crfppc
1. Medalie JH, Zyzanski SJ, Langa DM, Stange KC. The family in family practice: is it a reality? J Fam Pract 1998;46:390-96.
2. Curry HB. The family as our patient. J Fam Pract 1977;4:757-58.
3. Bauman MH, Grace NT. Family process and family practice. J Fam Pract 1977;4:1135-37.
4. Geyman JP. The family as the object of care in family practice. J Fam Pract 1977;5:571-75.
5. Rakel R. Principles of family medicine. Philadelphia, Pa: WB Saunders; 1977.
6. Schmidt DD. The family as the unit of medical care. J Fam Pract 1978;7:303-13.
7. Ransom D. The evolution from an individual to a family approach. In: Henads SG, ed. Principles of family systems in family medicine. New York, NY: Brunner-Mazel; 1985.
8. Chrstie-Seely J. Working with families in primary care: a systems approach to health and illness. New York, NY: Praeger Press; 1984.
9. Bothello RJ, Lue B-H, Fiscella K. Family involvement in routine health care. J Fam Pract 1996;42:572-76.
10. Rogers J, Holloway R. Family escorts of clinic patients. J Fam Pract 1997;44:213.-
11. Flocke S, Goodwin M, Stange K. The effect of a secondary patient on the family practice visit. J Fam Pract 1998;46:429-34.
12. Knishkowy B, Furst A, Fassberg Y, Anor E, Matthews S, Paz Y. Multiple family member visits to family physicians: terminology, classification, and implications. J Fam Pract 1991;32:57-63.
13. Green, LA, Wood M, Becker LA, et al. The ambulatory sentinel practice network: purpose, methods, and policies. J Fam Pract 1984;18:275-80.
14. Green LA, Miller RS, Reed FM, Iverson DC, Barley DE. How representative of typical practice are practice-based research networks? A report from the Ambulatory Sentinel Practice Network (ASPN). Arch Fam Med 1993;2:939-49.
15. Nutting PA, Baier M, Werner JF, Cutter G, Reed FM, Orzano AJ. Practice patterns of family physicians in practice-based research networks: a report from ASPN. J Am Board Fam Pract 1999;12:278-84.
16. Institute of Medicine Donaldson YK, Lohr KN, Vanselow NA, eds. Primary care: America’s health in a new era. Washington, DC: National Academy Press; 1996.
17. Green LA. How can family practice and primary care practice-based research networks contribute to medical effectiveness research? In: Hibbard H, Nutting PA, Grady ML. Primary care research: theory and methods. Rockville, Md: Publisher; 1991.
18. Green LA, Becker LA, Freeman WL, Elliott E, Iverson DC, Reed FM. Spontaneous abortion in primary care: a report from ASPN. J Am Board Fam Pract 1988;1:15-23.
19. Green LA, Reed FM, Miller RS, Iverson DC. Verification of data reported by practices for a study of spontaneous abortion: a report from ASPN. Fam Med 1988;20:189-91.
20. Aday, LA, Fleming GV, Andersen R. Access to medical care. Chicago, Ill: Pluribus Press; 1984.
21. Norcross WA, Ramirez C, Palinkas LA. The influence of women on the health care-seeking behavior of men. J Fam Pract 1996;43:475-80.
22. Lewis CE, Lewis MA. The potential impact of sexual equality on health. N Engl J Med 1977;297:863.-
23. Jaen CR, Stange KC, Nutting PA. The competing demands of primary care: a model for the delivery of clinical preventive services. J Fam Pract 1994;38:166-71.
24. Stange KC, Zyzanski SJ, Jaen CR, et al. Illuminating the ‘black box’: a description of 4454 patient visits to 138 family physicians. J Fam Pract 1998;46:377-89.
1. Medalie JH, Zyzanski SJ, Langa DM, Stange KC. The family in family practice: is it a reality? J Fam Pract 1998;46:390-96.
2. Curry HB. The family as our patient. J Fam Pract 1977;4:757-58.
3. Bauman MH, Grace NT. Family process and family practice. J Fam Pract 1977;4:1135-37.
4. Geyman JP. The family as the object of care in family practice. J Fam Pract 1977;5:571-75.
5. Rakel R. Principles of family medicine. Philadelphia, Pa: WB Saunders; 1977.
6. Schmidt DD. The family as the unit of medical care. J Fam Pract 1978;7:303-13.
7. Ransom D. The evolution from an individual to a family approach. In: Henads SG, ed. Principles of family systems in family medicine. New York, NY: Brunner-Mazel; 1985.
8. Chrstie-Seely J. Working with families in primary care: a systems approach to health and illness. New York, NY: Praeger Press; 1984.
9. Bothello RJ, Lue B-H, Fiscella K. Family involvement in routine health care. J Fam Pract 1996;42:572-76.
10. Rogers J, Holloway R. Family escorts of clinic patients. J Fam Pract 1997;44:213.-
11. Flocke S, Goodwin M, Stange K. The effect of a secondary patient on the family practice visit. J Fam Pract 1998;46:429-34.
12. Knishkowy B, Furst A, Fassberg Y, Anor E, Matthews S, Paz Y. Multiple family member visits to family physicians: terminology, classification, and implications. J Fam Pract 1991;32:57-63.
13. Green, LA, Wood M, Becker LA, et al. The ambulatory sentinel practice network: purpose, methods, and policies. J Fam Pract 1984;18:275-80.
14. Green LA, Miller RS, Reed FM, Iverson DC, Barley DE. How representative of typical practice are practice-based research networks? A report from the Ambulatory Sentinel Practice Network (ASPN). Arch Fam Med 1993;2:939-49.
15. Nutting PA, Baier M, Werner JF, Cutter G, Reed FM, Orzano AJ. Practice patterns of family physicians in practice-based research networks: a report from ASPN. J Am Board Fam Pract 1999;12:278-84.
16. Institute of Medicine Donaldson YK, Lohr KN, Vanselow NA, eds. Primary care: America’s health in a new era. Washington, DC: National Academy Press; 1996.
17. Green LA. How can family practice and primary care practice-based research networks contribute to medical effectiveness research? In: Hibbard H, Nutting PA, Grady ML. Primary care research: theory and methods. Rockville, Md: Publisher; 1991.
18. Green LA, Becker LA, Freeman WL, Elliott E, Iverson DC, Reed FM. Spontaneous abortion in primary care: a report from ASPN. J Am Board Fam Pract 1988;1:15-23.
19. Green LA, Reed FM, Miller RS, Iverson DC. Verification of data reported by practices for a study of spontaneous abortion: a report from ASPN. Fam Med 1988;20:189-91.
20. Aday, LA, Fleming GV, Andersen R. Access to medical care. Chicago, Ill: Pluribus Press; 1984.
21. Norcross WA, Ramirez C, Palinkas LA. The influence of women on the health care-seeking behavior of men. J Fam Pract 1996;43:475-80.
22. Lewis CE, Lewis MA. The potential impact of sexual equality on health. N Engl J Med 1977;297:863.-
23. Jaen CR, Stange KC, Nutting PA. The competing demands of primary care: a model for the delivery of clinical preventive services. J Fam Pract 1994;38:166-71.
24. Stange KC, Zyzanski SJ, Jaen CR, et al. Illuminating the ‘black box’: a description of 4454 patient visits to 138 family physicians. J Fam Pract 1998;46:377-89.