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Comparison of a Family Practice Teaching
Service and a Hospitalist Model: Costs, Charges, Length
of Stay, and Mortality
Leslie E. Tingle, MD; C. Tim Lambert, MD
Background and Objectives: One third of our nation’s
health care costs are incurred in the hospital. This
study compares the inpatient outcomes between a family
practice teaching service (FPTS) and a hospitalist group
in the same suburban community hospital. Methods: All
patients discharged by the hospitalist group or the
FPTS between April 1998 and June 1999 were included
for study if they had one of the 10 most frequent principal
diagnoses on discharge. The outcomes compared between
the groups were length of stay, mortality, total charges,
laboratory charges, radiology charges, and direct costs.
Student’s t test, chi-square, and analysis of variance
were used to compare the outcomes, after adjusting data
for severity of illness. Results: Mean severity of illness
for the FPTS patients was 2.42 and for the hospitalist
patients was 2.26, with higher scores indicating greater
severity of illness. After adjusting for severity of
illness, there were no differences between the two groups
of physicians for total charges, laboratory charges,
radiology charges, direct costs, length of stay, or
mortality rates. Conclusions: This study failed to demonstrate
a statistically significant difference in the use of
hospital resources between a family practice residency
teaching service and a hospitalist team. Given the outcomes
measured in this community teaching hospital, the residency
teaching service appears to be a financially competitive
model for delivery of inpatient care.
(Fam
Med 2001;33(7):511-5.)
Use
of a Template to Improve Documentation and Coding
Edward A. Rose, MD, MSA; ARti M. Deshikachar,
MD; Kendra L. Schwartz, MD, MSPH; Richard K. Severson,
PhD
Background
and Objectives: Accurate assignment of evaluation and
management (E&M) codes is a challenge for physicians.
Having guidelines close at hand during patient visits
might improve appropriateness and accuracy of E&M
coding. We developed a template based on a clinical
prediction rule for group A beta-hemolytic streptococcal
(GABHS) pharyngitis to improve documentation and coding
decisions. Methods: Fifty office visits for sore throat
were documented using templates and were compared with
50 sore throat visits that were documented using progress
notes. We counted history and physical examination items
and compared the level of service charged to the level
of service supported by the note. Results: Significantly
more history of present illness and physical examination
items were recorded on templates. Decisions related
to treatment for patients with a low probability of
GABHS were also improved by the templates. Templates
had no effect on billing and coding errors. Conclusions:
The template resulted in more-thorough documentation
but had no effect on coding and billing errors relative
to progress notes.
(Fam
Med 2001;33(7):516-21.)
Time
and Money: Effects of No-Shows at a Family Practice
Residency Clinic
Charity G. Moore, PhD; Patricia Wilson-Witherspoon,
MD; Janice C. Probst, PhD
Background:
When patients fail to appear for scheduled appointments,
the flow of patient care is interrupted, and clinic
productivity declines. This study investigated the impact
of failed appointments on a clinic by measuring time
and money lost after taking into account same-day treatment
patients (walk-ins). Methods: Schedule information was
retrieved for 4,055 visits over 20 business days. Data
were collected on appointment status (show, no-show,
cancel, walk-in), time allocated for the appointment,
charges for visit, date and time of the visit, and other
appointment information. Results: No-shows and cancellations
represented 31.1% of scheduled appointments and 32.2%
of scheduled time. Rates of failed appointments varied
by type of provider, patient demographics, and patient
status (new versus established). Walk-in patients replaced
61.0% of failed appointments but only 42.4% of the time
blocked for those appointments. Walk-in visits generated
89.5% of the charges associated with scheduled visits.
Over the course of a year, total revenue shortfalls
could range from 3% to 14% of total clinic income. Conclusions:
Failed appointments pose financial as well as administrative
problems for residency practices. Proactive reminder
systems are needed to promote patient attendance.
(Fam
Med 2001;33(7):522-7.)
Speaking
and Interruptions During Primary Care Office Visits
Donna R. Rhoades, PhD; Kay F. McFarland, MD;
W. Holmes Finch, MEd; Andrew O. Johnson
Background:
Patients and physicians value effective communication
and consider it an essential part of the medical encounter.
This study examined physician-patient communication
patterns, and interruptions in communication, during
patient visits with family practice and internal medicine
residents. Methods: Observational data obtained from
60 routine primary care office visits included the time
that resident physicians and patients spoke and the
number and types of interruptions. A total of 22 family
practice and internal medicine residents participated,
9 from family practice and 13 from internal medicine.
Results: Patients spoke, uninterrupted, an average of
12 seconds after the resident entered the room. One
fourth of the time, residents interrupted patients before
they finished speaking. Residents averaged interrupting
patients twice during a visit. The time with patients
averaged 11 minutes, with the patient speaking for about
4 minutes. Computer use during the office visit accounted
for more interruptions than beepers. Verbal interruptions,
a knock on the door, beeper interruptions, and computer
use all interfered with communication, and increased
frequency of interruptions are associated with less
favorable patient perceptions of the office visit. Female
residents interrupted their patients less often than
did male physicians. All residents interrupted female
patients more often than male patients. Early and increased
interruptions were associated with patients’ perception
that they should have talked more. Third-year residents
interrupted patients less frequently than did first-year
residents. Conclusions: Numerous interruptions occurred
during office visits. Gender was associated with the
pattern of interruptions. Physicians frequently interrupted
patients before the patients were finished speaking.
Computer use also interrupted physician-patient communication.
(Fam
Med 2001;33(7):528-32.)
Improving
Clinic Efficiency of a Family Medicine Teaching Clinic
George C. Xakellis, Jr, MD, MBA; Ann Bennett,
RN, MA
Background:
Teaching clinics are the heart of training programs
in family practice. It is in these training clinics
where residents develop their ambulatory practice habits.
Yet, little is know about the efficiency of these teaching
clinics. Methods: We conducted a time-and-motion study
of patient flow in a residency teaching clinic. Results:
During each half-day session, 7.8 ± 1.9 providers
were scheduled in clinic, and 55.5 ± 12.9 patients
were seen. First-year residents saw 3.55 patients per
half-day session, second-year residents saw 4.75 patients,
third-year residents saw 8.0 patients, faculty saw 8.22
patients, and urgent care saw 8.35 patients. The number
of patients scheduled was highly correlated with the
number of providers in clinic. Of the patients scheduled,
25% failed to keep their appointment, and 31% arrived
late. Neither rates of no-show patients nor rates of
late patients varied by level of provider. The mean
time patients spend in the clinic was 80.5 ±
30 minutes, with 17 ± 10 minutes spent registering,
18 ± 17 minutes spent being roomed, and 19 ±
16 minutes spent waiting for the provider. The physician
spent 27 ± 16 minutes with the patient, including
both face-to-face time and precepting time. Patients
who arrived on time waited significantly longer than
those who arrived late. Waiting time did not vary significantly
by level of physician. The time patients spent with
their doctor did vary significantly by level of physician;
first-year residents spent more time with their patients
than upper-level residents or faculty. Conclusions:
Significant variation exists in the patient flow through
the clinic. Patient volumes are significantly correlated
to the number of providers in clinic. Long waiting times
are due in part to long processing times and in part
to long waits in the exam room. Concerted multidimensional
efforts are needed to smooth out patient flow and improve
clinic efficiency.
(Fam
Med 2001;33(7):533-8.)
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