Does attending the same Doctor improve outcome in Chronic Disease

In   Issue .

Geoffrey Quail   MBBS, DDS(hons), M Med, MDSc, DTM&H, FRACGP, FRACDS, FACTM”.

ABSTRACT

The value of attending  the same medical practitioner in achieving  optimal  patient care. compliance with treatment and a favourable  outcome  is generally accepted and  there a many publications  to support this concept.  Most  however concerns  patient satisfaction and there is little  written of an objective nature. Asthma and diabetes allow  measurement of an outcome  end point and so asthma  was chosen  to study.  This work formed patt of an evaluation  of asthmatic  patients in a general practice setting  at the former 6 RAAF Hospital Lavetton.

Seven  parameters were quantitated  by doctors and patients and t he results show clearly that continuity of care by a single practitioner achieved a more favourable outcome  in the majority of cases.

Much has  been written about the doctor-patient relationship  and indeed the success of treatment  appears to some extent  to depend on the commitment of both parties to work  together for the best possible outcome. A 1990 study’  found  that over 90% of general  practitioner (GP) visits were  to the same doctor, however since then this has appeared to have decreased2 3

There is some  evidence that continuity  of care by a skilled empathetic practitioner  is an important contributor to quality  of care in family practice and is likely to lead to a more favourable outcome as measures by improved  compliance with treatment, patient knowledge of their complaint  and greater involvement in their own care than if patients  moved from doctor  to doctor. 3 4  Indeed, continuity of care is central to the philosophy  and teaching of family practice5. However, much of the discussion  has been of a subjective nature and there are few studies  reported  which compare treatment outcomes in a group of patients attending one as against random  practitioners and in these reports, the results are frequently inconclusive.

Chronic diseases such as diabetes and asthma  lend themselves to comparative studies of measurable parameters in relation to treatment outcome.  O ‘Connor 6 found that in adults with diabetes. those patients who identified a regular doctor were more likely to have better glycaemic control and to have received more recommended elements of care.

AIMS OF  STUDY

  1. to determine whet her those patients who attend the same practitioner demonstrate a greater degree of control of their asthma symptoms and a more favourable treatment outcome than was seen in a group of patients with  no particular doctor.
  1. to compare the degree of understanding of asthma and of the drugs prescribed in the two groups.
  2. to evaluate and compare patients’ management of an acute episode of asthma in the two groups.

METHOD

The study formed part of an overall evaluation of the standard of care provided for patients with asthma.   It was conducted in a general  practice setting – the Out Patients Department at 6 RAAF Hospital Laverton.

Approval  for the project was first obtained from the Australian Defence Medical Ethics Committee.

Letters were then written to all eight general practitioners working in the practice inviting them to ask their patients with asthma to join the study. It was emphasised that in addition to evaluating  the quality  of care, the exercise was to be under taken to ascertain  the severity of asthma in the Australian Defence Force (ADF}, and evaluate management. with a view to optimising quality of care.  In all but one case patients accepted the invitation.

Participating patients presented to the investigator and all agreed to sign a consent form. Subjects were assured  that their responses would be known only to the assessor;  they then completed a 25 part questionnaire based on the Asthma Management Plan (AMPHandbook)1.  The assessor was on hand to clarify any questions. At interview. respiratory function tests both before and after bronchodilatation with salbutamol  were performed  in accordance  with the recommendations  of Pierce and Johns R.

The results were collated and analysed. Confidence Intervals for proportions were calculated using the Exact Method. Where indicated. percentage response and p values were also derived.

In order to quantify t he results. acceptable answers to the six questions in which scoring is possible were constructed using the AMP Handbook and standard respiratory  medicine texts.  Marks were awarded according  to the degree of accuracy of the answers provided.

 

Questions  so quantified were:

what do you understand by the term asthma?

what do you think happens in an asthma attack?

what is the value of the peak flow meter?

how do you manage an attack?

what are the actions of drugs you use for asthma?

when do you take your drugs ?

The severity of asthma was graded as mild, moderate or severe

Patient Assessment of Severity Patients were asked to consider severity of their asthma in light of: number and frequency of symptoms early morning symptoms impact on work and lifestyle dependence on medication requirement of medical treatment If they thought their asthma well controlled and caused minimal disability patients were encouraged to grade it as mild.

If despite complying fully, asthma disrupted  their work or lifestyle. they should grade it as severe. For those who considered they did not fall into either group, it was suggested  they grade it as moderate.

Medical Assessment of Severity
For patients assessed  by a respiratory physician (32 cases). an indication  of severity  was provided in their report. Their work-u p included  a methacholine challenge in most cases.

GP medical assessment  was based on:
occurrence of sym ptoms
extent of disability
medical treatment  and its frequency
medication  required evaluation of pre and post beta agonist respiratory function tests

Asthma considered mild if:

episodic, infrequent,  only with recognised trigger factors, quickly resolved requires minimal  and infrequent medication, forced  expiratory flow rate> 75% of predicted value between  exacerbations and minimal response  to beta agonists

Asthma severe  if:
debilitating  symptoms occur daily or if long term
steroid therapy  required.
respiratory function tests (RFfs) indicative of severe obstructive airways disease

Patients  not conforming to these criteria were considered to have moderate  ast h ma

Doctors  initial impression of severity was compared with symptoms  found at audit together with results of respiratory function  tests.

M OD E L  ANSWERS TO QUES QUESTIONNAIRE:

Definition of  asthma: a condition  characterised  by symptoms of wheeze, cough and tightness  in chest  which results from increased  responsiveness of airways  to certain stimuli that cause constriction of the airway and increased bronchial secretions9

marks awarded if response  included  in lay terms the following features: symptoms  of wheeze, cough  and tightness in chest variable air flow obstruction increased responsiveness to stimuli

Mechanism: answer: irritation causes bronchial passages to contract and secretions to accumulate  within the air passages a pass recorded if mentioned one of: irritation causes secretions, bronchial constriction

Value of  Regular Peak Flow Measurements Answer: the device measures volume of air that can be forcibly expelled from the lungs and so gives an indication of current respiratory function and effect of beta agonists

Management of  an Attack: Patients were asked to describe their actions in the event of an asthma attack.  The Asthma Management Handbook Guidelines7  was used to establish the appropriateness of their management and their action plan was scored in accordance with the Guidelines.

For mild asthma as judged by symptoms. attendances frequency of medications. RFTs and notes on severity; judicious use of salbutamol and obtaining  medical advice promptly if problem persisted was the appropriate answer. For the more severe asthmatic, the above plus the use of the peak flow meter and use of cortico-steroids inccordance  with physician’s instructions was the required answer.Marks were awarded  in accordance with the Asthma Management Handbook.

RESULTS

There were ten females and thirty six males in the study  which is consistent with the patient population  in t he practice.Ages ranged from 18-55 years.  This too reflects the age range on the Base. In this report, figures represent percentages  unless specified.

ATTEND SAME  DOCTOR

Fifty four percent  of patients sought to attend the same  doctor where  possible.

Thu s:  n= 25 in the same doctor group

n= 21 in the random doctor group

RELATIONSHIP  WITH TREATING DOCTOR

93 % reported  a good relationship with their treating doctor.

Tables can be found in the full download edition 

PATIENTS CURRENTLY SMOKING

Smoking was marginally  less common  (12%)  in the same doctor compared to the Random Doctor group (19%) but was not statistically significant  (p=0.686).

FREQUENCY OF SYMPTOMS

There was no correlation between frequency  of symptoms and attendance  in the two groups (p=0.834).

TABLE 4.   MANAGEMENT OF  AN  ASTHMA ATTACK
Tables can be found in the full download edition

TABLE 5.   KNOWLEDGE ASSESSMEN T
Tables can be found in the full download edition

DISCUSSION

There was a relatively  low number of patients that attend the on e doctor (54%),  in the study This may be related to the frequency  with which defence force personnel move. between  bases and thus do not have sufficient time to establish a therapeutic relationship with a doctor. Patients  with mild disease were almost equally divided  between  those attending the same doctor and those not.  Of the nine with  more severe disease. five had a particular doctor  but the numbers are too small for the difference to be clinically significant.

It is reassuring to record that 93%  had a positive relationship w ith their doctor.  This equates with the data published by Papagiannisa 10 who found  that overall patient satisfaction  as 88.3%. Some  bias exists as the presence of the investigator  at t he time of response  may have influenced  some patients.

Attending the same doctor  was more  likely to result in  better management  of symptoms and  receiving a personalised  plan (tables  I,4). These findings are consistent with t hose of Foreno 11  who  found that a group of adolescents with a regular GP were  more likely to have their lung function  measured  and  an AMP than those with no family doctor.

There was a remarkable similarity in doctor and patient assessments  of the severity (table 2) with patients having more severe  asthma opting  to attend  one doctor. Medical review classified more cases  into t he moderate and severe groups  than did patients.

In the ADF, members medically unfit face discharge from the Service.  It is not surprising therefore that patients tendered to grade their asthmas as less severe than their doctor  (table 2). It is reassuring that those individuals with severe asthma endeavoured to attend the one doctor.

The benefit of attending the same  doctor  is illustrated by finding that no patient in the Same doctor  group worsened in the period between  initial  presentation  and final assessment  whereas 24%  did in the Random  group. Further, 32% in the Same doctor group improved  in contrast to 9% in the Random  group (table3).

Satisfactory  management of an attack  was much more likely if patients attended  the one doctor p=0.039. (table 4)This observation  supports the findings of Sweeneyl2  that lack of continuity  of care  was associated with additional  morbidity.

The Same doctor  group clearly  outscored the random group in all aspects of asthma education. In particular, if the marks for questions on the knowledge tested by asking for a definition of asthma (table 5b) and lung changes that produce symptoms (table 5c) are combined, only 2% of patients in the Same Doctor group failed in contrast  with 38% in the Random group.

Evaluation of responses to mailed questionnaires lend support to the hypothesis that patients attending t he same doctor are more likely to receive preventive health instruction5·8• 13  •   In this study the presence of the assessor whilst the questionnaire was completed  helped eliminate any ambiguity and provided a consistency in the grading of responses.  It is clear that those who routinely attended the same doctor had a significantly greater  understanding of asthma and its pathophysiology. In addition they were more likely to describe a personalised  asthma management plan and manage an attack  more satisfactorily.

Given that patients could reasonably expect better care from the same doctor, it is interesting to speculate why 50% now visit different general  practitioners. Convenience. time constraints. a simplistic view of medicine and a preference for specific doctors for certain complaints are some of the reasons proposed. Factors outside the patient’s control may also operate for example, availability of a certain doctor in a group practice or the use of a deputising service after hours. Stokes etaJI conducted a postal survey of 1.500 family practitioners  in three countries concerning the value they placed on continuity of care under three aspects: ability to provide different types of care, importance of this and their attitude towards continuity of care. They found that in all aspects they placed high value on being able to so provide (p< 0.00 I).

Whilst it is clear that in the study sample. continuity of care by the one practitioner achieved a more favourable outcome in the majority of case, it should be noted that this is not a randomised trial and so the results should be viewed in this context.

 

Acknowledgements

References

  1. Bridges Webb C et al. Morbidity  and treatment  in general  practice in Australia  1990-1991   Med 1 Aust; 1992: 152 Supp.
  2. Harris MF. Fi11h JF Continuity of care Med J A 1996; 167: 456-457.
 
  1. National  Health Strategies The future of general  practice; Canberra:  March  1 992.
  2. Wall EM Continuity  of care and family  medicine 1 Fam Pract 1 981: 1 3: 655-664.
 
  1. Royal Australian College of General  Practitioners  En try standards for general practice RAQCGP  1996.
  2. 0 Con nor PJ. Desai 11 J Fam Pract. 1998; 47: 290-297.
 
  1. National Asthma Cam paig n  Asthma  management Handbook 1996.
  2. 8. Pierce R. Johns DP Spirometry 1995 National Asthma
 
  1. Sears  MR Descr iptive epidemi  ology of asthma  Lancet; Supp 4. 1 -4.
 
  1. Papagiannis A Patien t sat isfaction  with information provided at an out-patient clinic Nat R esp Med 1 1995; 89: 673-676.
II . Foreno R. Bauman A. Asthma  prevalence and management in Australian adolescents 1 Adolescent  Health 1992:13: 707-71 2. 1 2. Sweeney  KG. Gray DP Patients  who do not receive cont i nuity of ca re. are they a vulnerable group?   Br J Gen Pract. 1995; 45: 133-1 35. 1 3. Quail  GG  Asthma in the Military   Aust  Military  Medici ne 2000; 9: 129-137.
  1. 14. Stokes Baker R I. Continuity of Care. Is the Family Doctor still important? Ann Fam Med 2005; 4: 353-358.