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Patient-reported health confidence is a valuable indicator of effective patient-clinician communication, which improves outcomes and reduces costly care use. This national survey examines health confidence attainment in the United States before the COVID pandemic strained health care resources. Health confidence was low for both the percentage of respondents who were financially secure (36%) and financially insecure (18%). Persons enrolled in employer- and union-sponsored plans, who had the highest household income, did not report higher levels of health confidence. Health policy should support the measurement and monitoring of health confidence in clinical practice to improve population health and maximize resource efficiency.

Purpose To rectify the significant mismatch observed between what matters to patients and what clinicians know, our research group developed a standardized assessment, information, and networking technology (SAINT). Methods Controlled trials and field tests involving more than 230,000 adults identified characteristics of a successful SAINT—www.HowsYourHealth.org—for primary care and community settings. Results Evidence supports SAINT effectiveness when the SAINT has a simple design that provides a service to patients and explicitly engages them in an information and communication network with their clinicians. This service orientation requires that an effective SAINT deliver easily interpretable patient reports that immediately guide provider actions. For example, our SAINT tracks patient-reported confidence that they can self-manage health problems, and providers can immediately act on patients’ verbatim descriptions of what they want or need to become more health confident. This information also supports current and future resource planning, and thereby fulfills another characteristic of a successful SAINT: contributing to health care reliability. Lastly, SAINTs must manage or evade the “C-monsters,” powerful obstacles to implementation that largely revolve around control and commercialism. Responses from more than 10,000 adult patients with diabetes illustrate how a successful SAINT offers a standard and expedient guide to managing each patient’s concerns and adjusting health services to better meet the needs of any large patient population. Conclusion Technologies that evolve to include the characteristics described here will deliver more effective tools for patients, providers, payers, and policymakers and give patients control over sharing their data with those who need it in real time.

During college and medical school, the author's summer employment acquainted him with members of organized crime families. After a full career as a primary care clinician and geriatrician with research on improving health care delivery, the author opines that several insights from organized crime should be of interest to health care professionals: (1) don't damage the host; (2) protect the brand; and (3) lead necessary adaption. From these insights, the author presents symptoms of failure evidenced by the US health care system, followed by several adaptations that would reduce the system's costs, improve its image, and address future challenges.

Introduction Current health care delivery relies on complex, computer-generated risk models constructed from insurance claims and medical record data. However, these models produce inaccurate predictions of risk levels for individual patients, do not explicitly guide care, and undermine health management investments in many patients at lesser risk. Therefore, this study prospectively validates a concise patient-reported risk assessment that addresses these inadequacies of computer-generated risk models. Methods Five measures with well-documented impacts on the use of health services are summed to create a “What Matters Index.” These measures are: 1) insufficient confidence to self-manage health problems, 2) pain, 3) bothersome emotions, 4) polypharmacy, and 5) adverse medication effects. We compare the sensitivity and predictive values of this index with two representative risk models in a population of 8619 Medicaid recipients. Results The patient-reported “What Matters Index” and the conventional risk models are found to exhibit similar sensitivities and predictive values for subsequent hospital or emergency room use. The “What Matters Index” is also reliable: akin to its performance during development, for patients with index scores of 1, 2, and ≥3, the odds ratios (with 95% confidence intervals) for subsequent hospitalization within 1 year, relative to patients with a score of 0, are 1.3 (1.1–1.6), 2.0 (1.6–2.4), and 3.4 (2.9–4.0), respectively; for emergency room use, the corresponding odds ratios are 1.3 (1.1–1.4), 1.9 (1.6–2.1), and 2.9 (2.6–3.3). Similar findings were replicated among smaller populations of 1061 mostly older patients from nine private practices and 4428 Medicaid patients without chronic conditions. Summary In contrast to complex computer-generated risk models, the brief patient-reported “What Matters Index” immediately and unambiguously identifies fundamental, remediable needs for each patient and more sensibly directs the delivery of services to patient categories based on their risk for subsequent costly care.

CARE Vital Signs refers to a standard form created by practices to Check what matters to patients, Act on that assessment, Reinforce the actions, and systematically Engineer or incorporate actions into staff roles and clinical processes. On its face, CARE Vital Signs is a deceptively simple tool that, when properly used, can help a practice attain levels of efficiency and quality. This article describes the rationale for CARE Vital Signs and the ways it can be used for the greatest benefit.

Scores of tools to measure outcomes that matter to patients have been developed over the past 30 years but few are used routinely at the point of care. Nelson and colleagues describe examples where they are used in primary and secondary care and argue for their wider uptake to improve quality of care

PURPOSE Pain, a common reason for visits to primary care physicians, is often not well managed. The objective of this study was to determine the effectiveness of pain management interventions suitable for primary care physicians. METHODS Patients from 14 rural primary care practices (47 physicians) who reported diverse pain problems with (n = 644) or without (n = 693) psy- chosocial problems were randomized to usual-care or intervention groups. All patients in the intervention group received information tailored to their prob- lems and concerns (INFO). These patients' physicians received feedback about their patients' problems and concerns (FEED). A nurse-educator (NE) telephoned patients with pain and psychosocial problems to teach problem-solving strategies and basic pain management skills. Outcomes were assessed with the Medical Outcomes Study 36-Item Short-Form and the Functional Interference Estimate at baseline, 6 months, and 12 months. RESULTS Patients with pain and psychosocial problems randomized to INFOFEED+NE signifi cantly improved on the bodily pain (P = .011), role physi- cal (P = .025), vitality (P

Objective: Nutritional care needs are overlooked in clinical practice. We review nutritional needs and describe an approach for improving nutritional care in clinical practice. Design: Data from a controlled trial and several population cohorts. Setting: Primary care practices and a population survey in New Hampshire and Vermont, USA. Subjects: The controlled trial involved 1651 persons aged 70+ years. The cohorts include information from 1879 persons aged 12+. Intervention: All patients completed standard surveys which included information about nutritional needs. 22 practices participated in the trial. Results: The higher the BMI, the less healthy the population. 15–30% of patients report problems or concerns with eating/weight and nutrition. Patients with problems or concerns are often bothered by other health and social problems. Patients who have productive interactions with clinicians have improved nutritional care and are more likely to report help with eating problems (68% vs 86%; Odds ratio 5.0 (95% CI: 0.9–27.0). Conclusions: Nutritional issues are common and complex. A productive provider-patient interaction can improve the nutritional care of patients. Essential elements for a productive interaction include an informed, educated patient and a provider (or clinical team) prepared to assess and manage the broad range of issues that are important to the patient. Technology facilitates necessary feedback between patient and provider.

OBJECTIVES The interest in the economic impact of new health care interventions has increased dramatically over recent years; however, the results can be highly variable depending upon the economic assumptions made and the approaches taken in collecting the data and in conducting the analyses. This paper describes experiences from the VA Cooperative Studies Program in measuring health care utilization and costs for studies that evaluate clinical interventions. METHODS Experiences from two multisite randomized clinical trials (RCTs) are highlighted to illustrate strategies used to measure costs by directly measuring health care utilization and economic data within the context of the trials. CONCLUSIONS Despite the substantial resources required to gather evidence about the cost of care for health care innovations, future VA multisite studies should include accepted health economic approaches to make important contributions to health planning and health policy within and outside the VA health care system.

Background: As patients directly experience harm from adverse events, investigators have proposed patient-report to complement professional reporting of adverse events. Objective: To investigate how an automated health assessment system can be used to identify adverse events. Design and setting: Internet survey responses from April 2003 to April 2005 involving communities and clinical practices across the USA. Patients: 44 860 adults aged 19–69 years. Outcome: Patient perceptions of adverse events experienced during the previous year. Independent legal review was also used to estimate how many patient-reports were serious enough to be potentially compensable. Results: Although patient reports of possible adverse events was low (1.4%), the percentage of adverse events was eight times higher for patients with the greatest burden of illness than for those with the least (3.4% vs 0.4%). Two expert malpractice attorneys agreed that 9% of the adverse events seemed to be serious. Conclusions: Patients will use internet technology to report their perceptions of health-related adverse events. Some of the patient-reported events reported will be serious.

Purpose: To describe practice patterns and beliefs of primary care physicians and urologists regarding early detection and treatment of prostate cancer. Subjects and Methods: National probability samples of primary care physicians (n = 444) and urologists (n = 394) completed mail survey instruments in 1995. Physicians were asked about their use of prostate-specific antigen (PSA) testing for men of different ages and their beliefs about the value of radical prostatectomy, external-beam radiation therapy, and watchful waiting for men with differing life expectancies. Results: Most primary care physicians report doing PSA tests during routine examination of men older than 50 years of age. The majority say they continue to do them on patients over 80 years and to refer men with abnormal values for biopsy. In contrast, only a minority of urologists would recommend PSA tests or biopsy for abnormal values for men over 75 years of age. More than 80% of primary care physicians and urologists doubt the value of radical prostatectomy for men with 10 years (67% versus 53%). Thirteen percent of primary care physicians and only 3% of urologists consider watchful waiting to be as appropriate as aggressive therapy for men with >10 years of life expectancy. Conclusions: Primary care physicians are more aggressive about PSA testing and referral for biopsy than most urologists recommend. Both groups recommend PSA testing and believe that aggressive treatment is more beneficial than existing evidence indicates.

Background: Radical prostatectomy is one of the most commonly used curative procedures for the treatment of localized prostate cancer. The probability that a patient will undergo additional cancer therapy after this procedure is largely unknown. Purpose: The objective was to determine the likelihood of additional cancer therapy after radical prostatectomy. Methods: Data for this study were derived from a linked dataset that combined information from the Surveillance, Epidemiology, and End Results Program and Medicare hospital and physician claims. Records were included in this study if patient histories met the following criteria: (a) residing in Connecticut, Washington (SeattlePuget Sound), or Georgia (Metropolitan Atlanta); (b) having been diagnosed with prostate cancer during the period from January 1,1985, through December 31,1991; (c) undergoing radical prostatectomy by December 31,1992; and (d) having no evidence of other types of cancer. Patients were considered to have had additional cancer therapy if they had had radiation therapy, orchiectomy, and/or androgen-deprivation therapy by injection after radical prostatectomy. The interval between the initial treatment and any follow-up treatment was calculated from the date of radical prostatectomy to the 1st day of the follow-up cancer therapy. All presented probabilities are based on Kaplan-Meier estimates. Results: The study population consisted of 3494 Medicare patients, 3173 of whom underwent radical prostatectomy within 3 months of prostate cancer diagnosis. Although radical prostatectomy is often reserved for localized cancer, less than 60% (1934) of patients whose records were included in this study had organ-confined disease, according to final surgical pathology. Overall, the 5-year cumulative incidence of having any additional cancer treatment after radical prostatectomy reached 34.9% (95% confidence interval [CI] = 31.5%-38.5%). For patients with pathologically organ-confined cancer, the 5-year cumulative incidence was 24.3% (95% CI = 20.0%-29.3%) overall and ranged from 15.6% (95% CI = 9.7%-24.5%) for well-differentiated cancer (Gleason scores 2-4) to 41.5% (95% CI = 27.9%-58.4%) for poorly differentiated cancer (Gleason scores 8-10). The corresponding figures for pathologically regional cancer were 22.7% (95% CI = 12.0%-40J%) and 68.1% (95% CI = 58.7%77.1%). Conclusion: Further treatment of prostate cancer was done in about one third of patients who had had a radical prostatectomy with curative intent and in about one quarter of patients who were found to have organ-confined disease. Implications: Given the common requirement for follow-up cancer treatments after radical prostatectomy and the uncertainties about the effectiveness of the various follow-up treatment strategies, further investigation of these treatments is warranted. [J Natl Cancer Inst 1996;88:166-73]

Objectives To assess patient responses to radical prostatectomy and its effects. Methods A national sample was taken of 1072 Medicare patients who underwent radical prostatectomy for prostate cancer (1988 through 1990) by mail, telephone, and personal interviews. The effects of the surgery and its complications on these patients' lives were studied through: (1) patient ratings of the extent to which sexual and urinary dysfunctions were “problems” in their lives; (2) two general measures of quality of life, the Mental Health Index and the General Health Index; (3) patient reports of how they felt about the results of treatment and whether they would choose surgery again. Results On average, dripping urine, particularly to the point where subjects were wearing pads, had a more significant effect on patients than loss of sexual function; incontinence had significant adverse effects on the measures of quality of life and selfreported results of surgery. Overall, postsurgical patients scored comparatively high on the quality of life measures (similar to a cohort of patients with benigh prostatic hyperplasia who had undergone transurethral resection of the prostate), reported feeling positive about the results (81%), and would choose surgical treatment again (89%). Nonetheless, there was variability in patient response to the effects of surgery. Conclusions The results demonstrate the ability of many Medicare patients to adapt to adverse outcomes, such as loss of sexual function and incontinence. They also provide evidence of the variability of individual patients' responses to surgical results and reinforce the importance of individualized decision making for patients facing a decision about radical prostatectomy for prostate cancer.

To estimate the probabilities of complications and follow-up treatment, a sample of Medicare patients who underwent radical prostatectomy (1988 through 1990) was surveyed by mail, telephone, and personal interview. Respondents reported their current status with respect to continence and sexual function as well as post-surgical treatments they had had to treat residual or recurrent cancer or surgical complications. Over 30 percent reported currently wearing pads or clamps to deal with wetness; over 40 percent said they drip urine when they cough or when their bladders are full; 23 percent reported daily wetting of more than a few drops. About 60 percent of patients reported having no full or partial erections since their surgery, and only 11 percent had any erections sufficient for intercourse during the month prior to the survey. Six percent had surgery after the radical prostatectomy to treat incontinence; 15 percent had treatments or used devices to help with sexual function; 20 percent report having had post-surgical treatment for urethral strictures. In addition 16 percent, 22 percent, and 28 percent reported follow-up treatment for cancer (radiation or androgen deprivation therapy) at two, three, and four years after radical prostatectomy. These estimates of complication and follow-up treatment rates are generally higher, and almost certainly more representative for older men, than estimates previously published. Patients and physicians may want to weight heavily the complications and need for follow-up treatments when considering radical prostatectomy for prostate cancer.

This study was designed to test the short-term effects of health assessment on the process of care and patient satisfaction. The 29 Chart physicians used the Dartmouth COOP Charts to measure their adult patients' health status during a single clinical encounter; the 27 control clinicians used no measure of health status. We compared the change between baseline and post-intervention information for a sample of all study clinicians' patients. Most of the patients were female (67%), well educated (70% had at least a college education) and young (approximately 90% were aged 59 years or younger). We found that the ordering of tests and procedures for women was increased by exposure to the COOP Charts (52% vs. 35%; p0.01); the effect in men was not as significant (37% vs. 23%: p = 0.06). Although women reported no change in satisfaction with care, men claimed that the clinician helped in the management of pain (p = 0.02). We conclude that the use of health status measures during a single clinical encounter in an HMO changes clinician test ordering behaviour and may improve the help male patients receive for pain conditions. The long-term impact of these management changes is not known.

With ever increasing pressure on doctors’ time, Iona Heath (doi: 10.1136/bmj.39532.671319.94) wonders whether primary care really meets the needs of elderly people at all, while John Wasson suggests ways for doctors to improve the care of older patients that don’t require extra resources or staffing

The Functional Interference Estimate (FIE) is a brief, 5-item self-report measure that assesses the degree to which pain interferes with daily functioning. While the FIE has demonstrated reliability and validity with a small normative sample, not much is known about its reliability and validity with a broad sample of individuals with pain. The current study presents FIE score means, variability estimates, reliability and validity data based on a large sample (n = 1,337) of primary care patients who report problematic pain. The FIE has excellent internal consistency and appears to have strong convergent validity with other well-established measures of function (e.g., SF-36 and Dartmouth COOP Charts). Because of its brevity and flexibility, the FIE may be a useful self-report measure of pain functional interference in clinical research on pain.

The relationship of trauma history to physical and emotional functioning in primary care pain patients was examined. Data were drawn from a mailed screening questionnaire for a larger study designed to evaluate an intervention for improving pain management in primary care. Results indicated that 50.4% of the pain patients reported experiencing at least one previous emotionally traumatic event. Further, 31% of patients with trauma history continued to be bothered by that experience. Finally, patients who continued to be significantly bothered by the trauma reported more pain, emotional distress, poorer social functioning, and more difficulty with engaging in their daily activities than did patients with either no trauma history or who had a trauma history but did not have bothersome thoughts of the trauma. These preliminary findings suggest that the experience of trauma alone was not related to additional impairments in physical and psychosocial functioning. However, the report that one continued to be bothered by thoughts of a trauma was associated with greater impairments in functioning.

To the Editor: In the United States, recent surveys suggest an increasing prevalence of non-medical tattooing in younger age cohorts compared to surveys performed only a few years earlier 1. Given the high use of the internet by young adults, we sought to estimate the current national prevalence of non-medical tattoos using a widely disseminated on-line health assessment system called HowsYourHealth.org2 open to researchers. This system asks individuals to answer questions about their health status, symptoms, concerns, management of chronic diseases, health care experiences, and self-care. During the period from September-November, 2008 we posted two additional questions on the website for respondents aged 14–69 years: (1) Have you ever had a tattoo on any part of your body? and (2) How old were you when you had your tattoo? A total of 452 respondents from 43 states responded. Using the survey data, we examined the prevalence of being tattooed by age and gender. We then compared health, social environment, and behavioral risk factors obtained from the survey between those who reported having had tattoo and those who had not tattooed. We used logistic regression and evaluated the potential confounding effects due to other factors. The prevalence of having a tattoo shows strikingly different age patterns. In contrast to the relative stability of adult male tattooing (i.e., among men between the ages of 18–49 years a prevalence of 18% and 50–69 years a prevalence of 16%), tattoos in women aged 18–49 years (a prevalence of 29%) appeared to be roughly 5 times higher than women aged 50 to 69 years (a prevalence of 7%) (Chi-squared p95%, making this site a unique and inexpensive resource for researchers. With consent, individuals could be enrolled into epidemiologic studies. A recognized limitation of web-based surveys is that they only include those using the internet, and in the present study, the website for our study. The main advantage, however, is the efficiency with which such data can be ascertained in an era of high internet use. Our survey suggests a rise in non-medical tattooing among younger women in the USA.

Authorities discourage prostate screening in men who are likely to die from causes other than prostate cancer.Use of prostate biopsy-a proxy for screening-in men aged 65 and older with limited life expectancy (i.e., estimated to be less than 10 years).Five percent samples of Part A (hospital) and Part B (physician) Medicare claims for 1993 through 1997.22% of all Medicare beneficiaries who underwent a prostate biopsy had a limited life expectancy, corresponding to a rate of 1420 biopsies per 100,000. This rate did not change significantly between 1993 and 1997. For men with a life expectancy greater than 10 years, the biopsy rate was 2,360 per 100,000. Among men with limited life expectancy, in the year following the biopsy, 1.6% had radical prostatectomy and 2.3% had external-beam radiation. Thirty-nine percent were hospitalized.A substantial proportion of prostate biopsies are being performed in men with a life expectancy of less than 10 years. These men are unlikely to benefit from the biopsy or subsequent treatment.

OBJECTIVE: Although longitudinal care constitutes the bulk of primary care, physicians receive little guidance on the fundamental question of how to time follow-up visits. We sought to identify important predictors of the revisit interval and to describe the variability in how physicians set these intervals when caring for patients with common medical conditions. DESIGN: Cross-sectional survey of physicians performed at the end of office visits for consecutive patients with hypertension, angina, diabetes, or musculoskeletal pain. PARTICIPANTS/SETTING: One hundred sixty-four patients under the care of 11 primary care physicians in the Dartmouth Primary Care Cooperative Research Network. MEASUREMENTS: The main outcome measures were the variability in mean revisit intervals across physicians and the proportion of explained variance by potential determinants of revisit intervals. We assessed the relation between the revisit interval (dependent variable) and three groups of independent variables, patient characteristics (e.g., age, physician perception of patient health), identification of individual physician, and physician characterization of the visit (e.g., routine visit, visit requiring a change in management, or visit occurring on a “hectic” day), using multiple regression that accounted for the natural grouping of patients within physician. MAIN RESULTS: Revisit intervals ranged from 1 week to over 1 year. The most common intervals were 12 and 16 weeks. Physicians’ perception of fair-poor health status and visits involving a change in management were most strongly related to shorter revisit intervals. In multivariate analyses, patient characteristics explained about 18% of the variance in revisit intervals, and adding identification of the individual provider doubled the explained variance to about 40%. Physician characterization of the visit increased explained variance to 57%. The average revisit interval adjusted for patient characteristics for each of the 11 physicians varied from 4 to 20 weeks. Although all physicians lengthened revisit intervals for routine visits and shortened them when changing management, the relative ranking of mean revisit intervals for each physician changed little for different visit characterizations—some physicians were consistently long and others were consistently short. CONCLUSION: Physicians vary widely in their recommendations for office revisits. Patient factors accounted for only a small part of this variation. Although physicians responded to visits in predictable ways, each physician appeared to have a unique set point for the length of the revisits interval.

In the past 30 years health service research has described how health care can be made better.1 Despite this unprecedented knowledge, health care remains seriously deficient in many ways.1– 3 Why isn’t it better? When asked that question, physicians most frequently contend that external regulations, medication costs, and lack of time for patient care are the problems.4 But most of us know that we health professionals contribute to the blight as well. Health care isn’t better because we have not designed the systems to deliver exactly what people want and need exactly when they want and need it. Our systems are more often a product of history and self-interest than of a design that matches our clinical resources to patient needs. Inadequate systems keep us from doing what we ought to do (the most common oversight) or cause us to do things we ought not to have done (the most visible errors).5 Several articles in this issue of the Annals of Family Medicine examine our oversights and errors.6– 8 Their findings are similar in most ways to studies of medical malpractice in the outpatient setting: lurking among most errors and harms is poor communication.9 A typical verbatim among the thousands of outpatient-reported harms reads: “Doctor did not listen to me regarding a medical problem and insisted that it was something else. Gave me prescription that burned my skin and caused great swelling. Could have been avoided if doctor had listened.” These comments reflect a mix of issues, but they almost always mention, in one way or another, poor communication.10 We health professionals and our patients are just not on the “same page.” How are we going to deal with these deficiencies given the realities of the demands on our practices? The answer from the experts is that if we want to be on the same page with our patients, we need to be aware, think smart, and think system. Being aware is the focus of the articles in this edition the Annals of Family Medicine. Thinking smart requires us to recognize that the more we help our patients become better at self-care, the better their outcomes and the fewer the harms.11– 13 We all have our good self-managing patients who show us their medication list and gently correct us when we are about to do something wrong. They live with their illnesses and manage their lives, medications, and tests. Across the nation about 40% of adult outpatients claim to be good at self-care. The rates of reported harms are lowest among chronic disease patients who report good self-management skills and report that they have received excellent explanations from their doctor (0.5 harms per 100 patients per year); patients with poor self-management skills who report inadequate communication have the highest rates of harms (9 harms per 100 patients per year).10 Helping poor self-managers become better and confident self-managers become more competent seems to be a good way to fix many health care deficiencies. Thinking system requires us to use every technique and process possible to ensure that we are on the same page. It can begin when vital signs are recorded in the office.14 It can be augmented by the use of interaction technologies designed specifically for busy office practitioners and their patients.10 Same-page care can be supported by e-mail, shared medical appointments,15 proactive telephone contact,16, 17 advanced access,18 and, of course, continuity of care.19 The challenge for us is to systematize same-page care. I believe that thinking smart and thinking system can be easily retrofitted into most busy practices.20 But even if the retrofit is not easy for some, it is essential that practices take action. “We are causing harm, and we need to stop it,” Don Berwick says. I hope that readers of this issue are as impatient as Don. Let’s all make it all better.

To the Editor:—For more than 40 years there has been interest in answering these questions: Is provider continuity beneficial and how do we measure it? From many correlative studies based on patient report, provider continuity seems beneficial.1 If we seek stronger evidence than correlative studies we have the results of one controlled, double-blind trial.2 When 776 patients were randomly placed into two groups (but each group had the same clinicians) provider continuity resulted in the following: a) higher patient assessments both of continuity and of clinician knowledge, thoroughness, and ability to provide excellent education; and b) fewer emergent admissions and shorter average length of stay. It is noteworthy that continuity per se influenced several patient perceptions of care, (such as clinician knowledge and ability to provide excellent education), even when the clinicians in the continuity and discontinuity groups were the same. Regarding measurement, Rodriguez et al.1 in their correlative study recapitulate the fact that patient-reported measures of provider continuity and “administrative measures” give different results. The one double-blind, controlled trial documented decades ago that “patient responses were not sensitive to low continuity of care indices: when the measured continuity of care index was less than 0.25, 51% of patients claimed continuity as compared with 83% of the patients who claimed continuity when the index was greater than 0.60.”2 From a statistical perspective both the correlative and controlled trial results confirm evidence of bias in patient report about continuity of care. This is old news and consistent with the fact that humans generalize from their good and bad experiences. Yet, based on their confirmation of old news, Rodriguez et al. now assert that “studies and quality initiatives seeking to evaluate visit continuity should rely on administrative measures whenever possible.” I hope that the elimination of patient report is not the end result the authors intend. Imagine a future in which we are presented with only statistically different administrative indices (using Rodriguez et al.’s method) of 0.53 from one setting and 0.48 from another. We might grasp the statistical implications of the observed difference between the settings. But how would we understand let alone “rely on” these particular indices when such indices: a) are subject to considerable bias,3,4 and b) tell us nothing about how the patients interpret the continuity of care they are receiving?

With ever increasing pressure on doctors’ time, Iona Heath (doi: 10.1136/bmj.39532.671319.94) wonders whether primary care really meets the needs of elderly people at all, while John Wasson suggests ways for doctors to improve the care of older patients that don’t require extra resources or staffing

Face-to-face interaction during a clinic visit is the traditional method for delivering medical care and communicating with patients. But this tradition is being challenged by a simple, inexpensive communication tool, the telephone. In this issue of JGIM, Marcantonio et al. show that the telephone can be an aid for diagnosis,1 while Delichatsios et al. describe possible benefits from its use for assessment, triage, and treatment.2 Telephone care has also been shown to improve preventive care and the management of several chronic conditions.3 Should doctors discard face-to-face medicine and move their practices to the telephone booth? On the one hand, this proposal is not as far-fetched as it might sound, at least in certain circumstances. Less than 10 years ago we had great difficulty convincing our institutional review board that it was ethical to substitute the telephone for routine follow-up.4 We found that substituting two telephone calls for one routine clinic visit improved several patient outcomes, reduced hospitalization, and saved money. Many now embrace the substitution of the telephone for some face-to-face visits. On the other hand, given the current lack of even a rudimentary classification scheme—one might call it a directory for telephone care—it is difficult to determine the circumstances for which telephone care is likely to be effective. A 1997 review of 66 controlled trials of telephone care highlights how little is known. Telephone contact was usually initiated by a nurse (40%) or nonprofessional staff (20%).3 Only 3% of the reviewed studies reflected approaches initiated by a physician, and 8% by the patient. It is very difficult to determine whether the medical staff person initiating telephone contact was a regular provider of care or a new, unfamiliar provider. The nature of the contact was follow-up and counseling in 40% and telephone reminders in 33% of cases. Few controlled trials examined the impact of telephone care on access, diagnosis, or care planning. The costs of such care were seldom addressed. In brief, when examined using the simplest classification scheme of health and medical care,5 the emerging literature about telephone care has significant gaps. The field of telephone care is mature enough to benefit from a classification system, a standard and succinct directory of what it is and how it works. In providing directory assistance to their readers, authors should uniformly report who initiated the contact and the familiarity of the patient with the person on the other end of the line. Authors might also provide explicit information about the patient needs and outcomes being addressed using standard nomenclature;6 the specific processes for which the telephone is being exploited (access, assessment, diagnosis, treatment, follow-up, or referral); and the principal nature of the interaction (simple information transfer, education, or care planning). Let's illustrate the advantages of directory assistance for telephone care by applying this scheme to the articles by Marcantonio and Delichatsios. Marcantonio et al. do not tell us specifically who initiated the contact to the patient or whether that person was familiar with the patient. The contact was for assessment and diagnosis and involved information transfer only: it was not an interaction designed to directly impact patient outcomes. Delichatsios et al. describe outcomes of patient-initiated telephone contacts to a physician telephone coverage service. The physicians were not the patients' primary physicians. The main outcome measures were symptom relief and satisfaction with care. The telephone contact was exploited as a tool for access, assessment, diagnosis, treatment, follow-up, and referral. The nature of the interaction was simple information transfer and education (reassurance). According to these classification criteria, the article by Delichatsios et al. clearly identifies the characteristics and value of a certain type of telephone care. The article by Marcantonio et al. imparts less information. In summary, a standard directory of telephone care should assist readers and clinical investigators in communicating more precisely and clearly about telephone care by describing what it is and how it works. Using such a standard approach, readers can quickly determine the potential application of telephone care to their patients and settings. Investigators can use these standards to guide their choices of research questions and outcome measures.—JohnH. W asson, MD,Center for Aging, Dartmouth Medical School, Hanover, N.H.

Address correspondence to: John H. Wasson, MD, (170), Veterans Administration Hospital, White River Junction, VT 05001. nurse practitioners, and four physician assistants) at a rural Veterans Administration General Medical Clinic (VAGMC) provided medical care to the study patients during the study period 1979-1982. To be included in the study, a patient had to be a man aged 55 years or older, and his one-way mileage from home to the VAGMC had to be 90 miles or less. Patients