Delivering preventive services is one of the most important things family physicians do for their patients. Numerous studies show that, when patients come in for dedicated well-care visits, family physicians do a good job of screening for early asymptomatic disease, providing health-habit counseling and giving immunizations. But the fact is, most patients see their family physicians for treatment of acute illness or for management of chronic conditions. Although these patients are often at highest risk for preventable disease, they don't always receive the benefits of prevention because they seldom come in for health maintenance exams. One way family physicians can combat this is to think of illness visits as yet another opportunity to address prevention.
Illuminating the ‘black box’ of primary care
This article continues our series offering practical lessons from the Direct Observation of Primary Care Study, which was funded by the National Institutes of Health and conducted by the Center for Research in Family Practice and Primary Care, with support from the AAFP. The study demonstrates the complexities of the patient visit, the demands of real-world practice and the value of primary care, issues that policymakers, the public and even clinicians have not fully understood. Researchers used a multi-method approach, including direct observation, to study 4,454 patient visits to 138 family physicians in 84 practice sites.
Using data from the Direct Observation of Primary Care (DOPC) Study, including 3,547 directly observed illness visits to 138 family physicians, we found that many family physicians are already employing this “opportunistic” strategy.1 At least one service recommended by the U.S. Preventive Services Task Force2 was delivered during nearly one-third of illness visits. Health-habit advice was the most common opportunistic preventive service; immunization and screening tests were also provided, but at lower rates. A separate analysis of the study data found that opportunistic prevention was most often delivered to new patients and patients who had fewer visits to the practice in the past year, as well as to patients who were overweight, smoked or drank alcohol.3
But what was the impact of “opportunistic prevention” on length of visits and patient satisfaction? According to the data, illness visits that included preventive services were an average of 2.1 minutes longer than those without prevention; however, individual preventive services delivered in illness visits (such as advice about tobacco cessation, diet or exercise) often took less than one minute each. Ordering an immunization or cholesterol screening test also took very limited amounts of physician time, although staff time was required in the actual delivery of these services. In addition, patient satisfaction with illness visits was the same regardless of whether preventive services were delivered. This suggests that family physicians integrate prevention into these visits in a way that meets patients' needs and expectations.
Based on the DOPC data, it is clear that illness visits are useful opportunities for delivering preventive services and that tailoring preventive services to the needs of high-risk patients is an effective opportunistic strategy. Such opportunistic prevention is among the “added values” of patient visits to their family physicians. Over time, these brief and effective preventive services can have a big impact on the health of patients, including the majority of Americans who don't come in regularly for well care.