A fundamental tenet of this book is that ambulatory care has distinctive characteristics that should shape practitioners’ approaches to patients. This chapter describes the territory of ambulatory care in the United States, as well as some of the proficiencies that are central to ambulatory practice.
The Territory of Ambulatory Practice
Who provides ambulatory care? What patients make ambulatory care visits? What problems do patients present at their visits? What ambulatory care is provided for these problems? To answer these questions, the United States National Ambulatory Medical Care Survey (NAMCS), started in 1973, has collected information periodically from a representative sample of physicians’ offices.
Office-Based Practitioners
Table 1.1 shows the distribution by specialty of the approximately 890 million visits to physicians’ offices in the United States during 2002. Of these visits, 18% were to the offices of internists and 24% were to the offices of general or family practitioners; 3% of all visits were to physician's assistants or nurse practitioners (1). This book is directed primarily to those physicians and other practitioners who provide primary care for adult patients.
Ambulatory Patients
The NAMCS definition of an ambulatory patient is “an individual presenting for personal health services who is neither bedridden nor currently admitted to any health care institution.” A critical expansion of this definition is that ambulatory or homebound patients (or members of their households) have most of the responsibility for carrying out their own care: They must administer treatments, monitor symptoms and functional status, adapt to the constraints imposed by illness, and decide how to deal with new problems when they arise. These characteristics have important implications for the care of ambulatory patients, as discussed later in this chapter and throughout this book.
Table 1.2 shows the age and sex distribution of the patients who made ambulatory visits to physicians’ offices in 2002. In that year, the annual number of office visits by adults ranged from 1.8 for people 15 to 24 years old to 7.2 for people age 75 years and older (1).
Problems of Ambulatory Patients
What types of problems are seen in ambulatory practice? Using the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM), participants in NAMCS were asked to name the principal reasons for the visits by patients. Table 1.3 lists the 20 most common diagnoses named in 2002. Because comorbidity, especially the coexistence of physical and mental morbidity, is very common in ambulatory patients, this list of principal reasons
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for visits tells only part of the story. Furthermore, at least half of ambulatory care visits are for symptoms, and a diagnosis that explains these symptoms is infrequently found (2). Ongoing research on common symptoms will contribute critical information for addressing the needs of ambulatory patients (see Kroenke and Laine, Investigating Symptoms, at http://www.hopkinsbayview.org/PAMreferences).
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TABLE 1.1 Number, Percent Distribution, and Annual Rate of Office Visits by Selected Physician Practice Characteristics: United States, 2002 |
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Ambulatory Care
In 2002, ambulatory care for adult patients provided by physicians who identified themselves as the patient's primary care provider had the following general characteristics (1):
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Average number of visits per week |
92 |
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Average time with physician |
16 to 20 minutes |
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≥6 visits in past year (% of patients) |
24% |
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Status of patient (% of visits) |
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Established patient |
91% |
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New problem |
33% |
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Drug mentions (% of visits) |
74% to 77% |
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Average number of drug mentions per visit |
2 drugs |
Table 1.4 shows the proportion of ambulatory care visits reimbursed by each of the primary sources of payment in the United States for the year 2002.
In addition to office visits, telephone and e-mail encounters and house calls are important in the care of ambulatory patients. Telephone and e-mail encounters enable physicians and patients to handle many problems efficiently. (See Reisman and Stevens,http://www.hopkinsbayview.org/PAMreferences.) Home visits are helpful for providing care to patients who are too frail to make office visits and for learning facts about patients’ home conditions that may facilitate management of their problems at future office visits. In 2002, primary care physicians practicing in the United States reported the following regarding nonoffice encounters with patients (1).
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Office Visits |
Telephone Consultation |
E-mail Consultation |
Home Visits |
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Percent of physicians |
73% |
7% |
19% |
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Average number per week |
92 |
26 |
6 |
11 |
Self-Care and Alternative Care
Before making visits to physicians, patients usually attempt to diagnose and treat their own symptoms. Additionally, in the past decade an increasing number of patients in the United States report using one or more of the many types of complementary and alternative care medicines that are described in Chapter 5 (3).
Classic studies of self-care in a number of countries show that at any one time approximately 30% of persons are taking nonprescribed medications or are engaged in self-care for a problem for which they have not consulted a physician (4). Over-the-counter (OTC) medications now account for the majority of medicines taken in the United States (5). The frequency distribution of conditions managed by self-care was estimated by Fry (6), on the basis of many years of general practice in a community well
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known to him, as 25% upper respiratory tract infections, 20% musculoskeletal symptoms, 20% emotional problems, 10% acute gastrointestinal symptoms, 5% skin rashes, and 20% miscellaneous other symptoms. Both the changing status of drugs from prescription to OTC formulations and the availability of herbal remedies without a prescription (see Chapter 5) have expanded the “formulary” that patients can access for self-care.
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TABLE 1.2 Number, Percent Distribution, and Annual Rate of Office Visits by Patient's Age, Sex, and Race: United States, 2002 |
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Table 1.5, adapted from NAMCS data, shows the time interval between the onset of a new problem and the decision to go to a physician (i.e., the duration of self-care) for a number of common conditions. Not surprisingly, patients with lacerations presented within 1 day, patients with symptoms of acute infection and chest pain tended to present within 1 week, and patients with most other problems tended to present after at least 1 week of self-care.
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TABLE 1.3 The 20 Most Common Primary Diagnoses in Ambulatory Care Visits: United States, 2002 |
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Self-care before professional care is an important way in which the patient, not the practitioner, makes the decisions in the domain of ambulatory medicine. The patient's primary role in carrying out the plan of care after an office visit has already been emphasized. These two features confirm the primacy of the patient's actions in determining the course of events in ambulatory medicine.
Temporal Dimension of Ambulatory Medicine
The information from the NAMCS does not illuminate the longitudinal nature of ambulatory care. Table 1.6 shows
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the 5-year profile of care for an elderly woman. This patient's story illustrates each of the following important questions, for which only the passage of time provides the answers:
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TABLE 1.4 Number and Percent Distribution of Office Visits by Primary Expected Source of Payment: United States, 2002 |
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TABLE 1.5 Percentage Distribution of New Problem Office Visits by Time Since Onset of Complaint or Symptom, According to Selected Principal Reasons for Visit: United States, 1977 |
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Goals of Ambulatory Care
Patient Expectations
The goals of ambulatory care are strongly influenced by the expectations of patients for their day to day activities in the community. When they make office visits, ambulatory patients are seeking help to relieve symptoms or to cure, ameliorate, or prevent illness, so that they can maintain or resume valued activities. Depending on the severity of their problems, outpatients may be greatly, moderately, or not at all constrained from attaining their expectations. By virtue of living in the community, they (or other caregivers) play an active role in how these expectations are addressed, in contrast to the more passive role played by hospitalized patients.
Implications for Practice
To determine how any patient is doing, it is helpful to be aware of the patient's particular expectations and how well the patient is meeting them. This usually involves learning about the makeup of the patient's current household and
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the patient's usual role in the family, the patient's occupation and level of formal education, and the patient's valued activities. It is also helpful to be aware of the developmental tasks that may be relevant to a patient's family. Table 1.7 lists tasks that are typical of the various stages in the life cycle of a family. The significance of this information can be illustrated by the common example of a middle-aged man who has had an uncomplicated myocardial infarction. After 3 months, the patient might be assessed as “status postmyocardial infarction—doing well.” If he has resumed work and other valued activities, then he is probably “doing well.” If he is not back at work, is financially stressed, and his wife reports that he has become irritable, then he is not doing well and the situation requires evaluation.
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TABLE 1.6 Profile of 5 Years in the Care of an Elderly Patient (each problem italicized) |
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TABLE 1.7 Factors to Consider in the Family Life Cycle State of One's Patient |
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Awareness of a patient's life circumstances is particularly important in preventive care (see Chapter 14), in which the patient's degree of wellness, rather than degree of illness, is assessed. Assessing wellness means determining a patient's goals, learning whether a patient engages in health-promoting behaviors and identifying what health risks the patient has. For example, a 45-year-old mother who seeks balance between her professional and family life, is happily married, is free of chronic disease, has stopped smoking, has had periodic negative Papanicolaou (Pap) smears, exercises regularly, and drinks alcohol only socially would be assessed as very well. If everything was the same except that the patient smoked two packs of cigarettes daily, she would be assessed as only moderately well because of the major risk posed by heavy tobacco exposure. If she was feeling quite aimless, was recently divorced, had stopped seeing friends, and was smoking and drinking heavily, she would be assessed as not very well, even though she might not complain of any particular symptoms or have objective evidence of any disease.
The approach to addressing the goals of ambulatory patients described here was recently summarized as shifting one's focus from a disease orientation to a focus on the meanings that patients attach to their illness, which typically consists of multiple diseases and symptoms in chronically ill patients (7).
Core Proficiencies for Ambulatory Practice
Information such as that provided by the NAMCS (discussed earlier) has implications for several core proficiencies needed in the practice of ambulatory medicine. These core proficiencies include medication prescribing, documentation of care, coordination of care, discharge planning, cost containment, evidence-based decision making, patient-centered communication, patient education and promotion of healthy behavior, and integration of prevention into practice. Chapters 2, 3, 4, and 14, respectively, address in depth the latter four areas.
Medication Prescribing
Clinical pharmacology is the source for the many details needed for appropriate prescribing of medications. Apart from the impact of a medication on a patient's condition, it is important to be aware of the following aspects of each drug that one prescribes:
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and primary refractoriness to the drug; how to recognize and manage each of these problems.
Because prescription of medications is the single most common action taken by nonsurgical clinicians in ambulatory practice (see above), rapid access to this practical information through published or electronic resources is particularly important.
Documentation of Care
Documentation of care in the ambulatory record serves several purposes. It provides for rapid access by practitioners to the information they need for clinical decision making at serial visits; justification of the level of care for which payers are billed; and data accessibility for a quality-of-care audit. Documentation of care also stands as legal evidence of a practitioner's actions. Both paper and electronic records can be designed to meet these purposes. In 2002, approximately 18% of primary care physicians used electronic clinical records (1). For a number of compelling reasons, the implementation of electronic health records, with connectivity between users, is regarded as a national priority in the United States (8).
A well-structured primary care record, either paper or electronic, includes the following components and information:
To document patient education, prescriptions, and work slips, it is helpful to use forms that make duplicates for mounting in the patient's record.
Coordination of Care
Another proficiency important in ambulatory practice is skill in coordinating the patient's care. Coordination of care refers to referral for, awareness of, and interpretation of the services that a patient may need or receive. The availability of many diagnostic and consultative services requires generalists (1) to be prudent in recommending them and in using the information they provide, and (2) to be aware of the cost of a service, the nature of the experience the patient will undergo, and the likelihood that the service will be of value to the patient.
The services recommended for patients may involve permanent, temporary, or partial transfer of responsibility for the patient's care (e.g., to a surgeon), or they may be strictly consultative, meaning that they provide information to be used by the referring physician or practitioner (ranging from diagnostic test results to a consultant's suggestions).
Approximately 7.3% of office visits include referral of the patient to another physician (1). The following general guidelines are important in coordinating the care of a patient who is referred for consultation:
The finding in a 2003 survey that in one of seven primary care office visits information critical for decision making is missing, speaks to the challenge presented by the coordinating role of the generalist practitioner (9). As noted above, the wider use of interconnected electronic clinical records has the potential to greatly streamline this role.
Patients sometimes obtain services for medical problems without referral by their personal physician. These most often include visits to emergency departments, to specialists such as ophthalmologists, or to alternative practitioners (3). Being aware of these visits is another way in which generalists coordinate their patients’ care. When they obtain services elsewhere, patients can play an essential role by requesting that information be sent to their personal physicians.
Discharge Planning
Admission of the patient to the hospital follows approximately 0.5% of office visits (1). For each admission,
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hospital discharge usually means the return of the patient to ambulatory care by the patient's primary physician. Each of the generic proficiencies described earlier is especially important when patients make the transition from dependence on hospital personnel to dependence on themselves or their families for management of their medical problems.
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FIGURE 1.1. Example of a primary care front sheet. |
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FIGURE 1.2. Example of a clinical flow sheet, which aligns treatments and clinical/laboratory parameters. |
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TABLE 1.8 Information that Subspecialty Consultants Generally Need from the Referring Physician |
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Beginning with the implementation of the federal prospective payment systems in the 1980s, and continuing with the growth of managed care in the 1990s, very short hospital stays have become the norm in the United States. By the beginning of the 21st century, inpatient care by hospitalists had become common and had been shown to add to the efficiency of hospital care (10). These changes have drawn attention to the elements of effective discharge planning, such as ensuring that patients and their families have a good understanding of the plan of care, ensuring that a concise discharge summary goes promptly to the practitioner or to the setting responsible for postdischarge care, and using home health services or other community-based services to help patients complete care that was previously carried out during prolonged hospital stays. Chapter 9 provides detailed information about home health services.
Cost Containment and Managed Care
Because of the extraordinary increase in available medical services in the past three decades and because of the parallel increase in the cost and the use of these services, cost containment in medical care is generally recognized as a national imperative. Managed care—that is, health care in which delivery and financing of care are linked in a variety of models—has emerged as a major strategy for containing costs. Managed care plans make arrangements with physicians ranging from directly employing them (staff-model HMOs) to contracting with them (group-model, network-model, and independent practice association–model) (11). Based on the 2002 NAMCS data from primary care physicians, 40% have 3 to 10 and 35% have more than 10 managed care contracts (1).
The goals of containing costs while providing high-quality care have critical implications for generalist physicians and practitioners, because it is they who coordinate much of the medical care provided in our society (12). These goals can be addressed in a number of ways, including the following:
Before the era of managed care, fee-for-service reimbursement tended to foster excessive use of laboratory tests and costly procedures. There were few external incentives for practitioners to engage in the inquiry, observation, counseling, and decision making that would have obviated much inappropriate use of health services. Besides fostering more appropriate spending of health care dollars, managed care may foster inappropriately low use of laboratory tests and costly procedures. Fortunately, direct incentives to practitioners to reduce the use of such services have been banned in most settings. To the extent that managed care rewards physicians for cognitive services—and does not overburden them with administrative hurdles or force upon them unreasonable productivity expectations—it has the potential both to promote the health of patients and to reduce the unnecessary use of costly services.
Specific References
For annotated General References and resources related to this chapter, visit http://www.hopkinsbayview.org/PAMreferences.
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