Video decision support tool for advance care planning in dementia: randomised controlled trial

Objective To evaluate the effect of a video decision support tool on the preferences for future medical care in older people if they develop advanced dementia, and the stability of those preferences after six weeks

The time burden of overweight and obesity in primary care

<p>Abstract</p> <p>Background</p> <p>Overweight and obesity are associated with many conditions treated in primary care. Our objectives were: 1) to determine the frequency of weight-related conditions in a national sample of outpatient visits in the United States; 2) to establish the percentage of diagnosis codes and visit codes attributable to overweight and obesity; and 3) to estimate time spent to address these conditions, including time attributable to overweight and obesity itself.</p> <p>Methods</p> <p>We analyzed primary care visits from the 2005 and 2006 National Ambulatory Medical Care Survey (NAMCS) in the United States. Weight-related conditions included diabetes, hypertension, hyperlipidemia, obesity, cardiovascular disease, osteoarthritis, and low back pain. We used multivariable logistic regression to estimate an odds ratio for each weight-related condition, which we then converted to an attributable fraction (AF). The AF represents the percentage of diagnosis codes and visit codes attributable to excess weight for that condition. We then divided total visit time among all diagnoses and clinical items addressed at the primary care visit. Finally, to calculate the time attributable to overweight and obesity, we multiplied the AFs by the time spent on each weight-related condition.</p> <p>Results</p> <p>The total number of clinical items (diagnoses + medications + tests + counseling) was estimated to be 7.6 per patient, of which 2.2 were weight-related. Of a total visit time of 21.77 minutes, time spent addressing weight-related conditions was 5.65 minutes (30%), including 1.75 minutes (8.0%) attributable to overweight and obesity.</p> <p>Conclusions</p> <p>Approximately 8% of time from primary care visits is attributable to overweight and obesity. This estimate is conservative because the NAMCS only allows for coding of three diagnoses addressed per visit. Estimates of the time burden of overweight and obesity provide data to prioritize weight management for prevention and treatment.</p

The Increasing Number of Clinical Items Addressed During the Time of Adult Primary Care Visits

BACKGROUND: Primary care physicians report that there is insufficient time to meet patients\u27 needs during clinical visits, but visit time has increased over the past decade. OBJECTIVE: To determine whether the number of clinical items addressed during the primary care visit has increased, and if so, whether this has been associated with changes in visit length and the pace of clinical work. DESIGN: Analysis of non-hospital-based adult primary care visits from 1997 to 2005, as reported in the National Ambulatory Medical Care Survey. PARTICIPANTS: A total of 46,431 adult primary care visits. MEASUREMENTS: We assessed changes over time for the total number of clinical items addressed per visit (including diagnoses, medications, tests ordered, and counseling), visit duration, and average available time per clinical item. In adjusted analyses we controlled for patient and physician characteristics. RESULTS: The number of clinical items addressed per visit increased from 5.4 to 7.1 from 1997 to 2005 (p \u3c 0.001). Visit duration concurrently increased from 18.0 to 20.9 min (p \u3c 0.001). The increase in the number of clinical items outpaced the increase in duration, resulting in a decrease in time per clinical item from 4.4 to 3.8 (p = 0.04). These changes occurred across patient age and payer status and were confirmed in adjusted analyses. CONCLUSIONS: The volume of work associated with primary care visits has increased to a greater extent than has visit duration, resulting in less available time to address individual items. These findings have important implications for reimbursing physician time and improving the quality of care