Patient-Centered Care is Associated with Decreased Health Care Utilization

Klea D. Bertakis; Rahman Azari

doi:10.3122/jabfm.2011.03.100170

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Table 1.

Individual Davis Observation Codes and Clusters

Codes in Each Cluster	Abbreviated Definitions of Codes
Technical cluster
Structuring interaction	Discussing what is to be accomplished in current interactions
History taking	Physician inquiring about or patient describing details related to the current complaint or to prior illnesses
Family information	Discussing family, medical, or social history and/or current family functioning
Physical examination	Any aspect of physical examination of patient
Evaluation feedback	Physician telling patient about results of history, physical, laboratory work, etc.
Planning treatment	Physician prescribing a medication, diagnostic, or treatment plan
Treatment effects	Physician inquiring about or patient describing result of ongoing therapeutic intervention
Procedure	Any treatment or diagnostic procedure done in office
Health behavior cluster
Compliance	Discussing previously requested behavior
Health education	Physician presenting information to patient regarding health
Health promotion	Physician asking for change in patient’s behavior to increase or promote health
Nutrition	Any question about or discussion about nutrition
Exercise	Any question about or discussion about exercise
Addiction cluster
Substance use	Any question about or discussion of drinking alcohol or use of other substances
Smoking behavior	Any question about or discussion of smoking or use of tobacco
Patient activation cluster
Health knowledge	Physician asking or patient spontaneously offering what patient knows or believes about health and disease
Patient question	Patient asking question
Chatting	Discussing topics not related to current visit
Preventive service cluster
Preventive service	Physician discussing, planning, or performing any screening task for disease prevention
Counseling Cluster
Counseling	Physician discussing interpersonal relations or current emotional state of patient or patient’s family

Those Davis Observation Codes in bold print are included in the modified version of DOC, which measures Patient-Centered Care.

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Table 2.

Sociodemographic and Health Data for All Study Patients (n = 509) and Patients with Yearling Patient-Centered Care Below (n = 254) and Greater than or Equal to (n = 255) the Median

	All Patients (n = 509)	<Median (n = 254)	≥Median (n = 255)
Sex (%)
Male	38.11	39.37	36.86
Female	61.89	60.63	61.14
Age (mean years [SD])	41.74 (14.73)	42.24 (14.30)	41.24 (15.15)
Education (mean years [SD])	12.61 (2.73)	12.32 (2.59)	12.89 (2.85)
Income^* (%)
<$10,000	49.11	55.56	42.69
$10,000–$19,999	24.75	24.60	24.90
$20,000–$29,999	10.50	10.32	10.67
$30,000–$39,999	6.14	2.38	9.88
$40,000–$49,999	4.16	3.97	4.35
≥$50,000	5.35	3.17	7.51
Physical health status^† (n [mean])	40.44 (11.88)	39.01 (12.07)	41.87 (11.53)
Mental health status^† (n [mean])	43.99 (12.55)	43.92 (12.36)	44.05 (12.76)
BMI (mean)	29.76 (8.39)	29.19 (7.85)	30.33 (8.87)
Alcohol abuse (%)	7.69	9.84	5.53
Smoker (%)	67.85	74.41	61.26

↵* Income data was available for 505 study patients.
↵† Physical health status and mental health status were measured by the physical and mental components of the Medical Outcomes Study Short Form-36. The established means for these are 50 (SD, 10). BMI, body mass index.

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Table 3.

Descriptive Statistics for Medical Resource Use and Charges (n = 509)

	Below Median Patient-Centered Care (n = 254)		Equal or Above Median Patient-Centered Care (n = 255)
	Mean (SD)	Median (Range)	Mean (SD)	Median (Range)
Type of visits
Primary care	3.64 (2.94)	3.00 (1–24.00)	3.66 (3.38)	3.00 (1–24.00)
Specialty care	2.94 (4.50)	1.00 (0–26.00)	2.22 (4.06)	0.00 (0–21.00)
Emergency department	0.35 (0.98)	0.00 (0–8.00)	0.22 (0.65)	0.00 (0–4.00)
Hospitalizations	0.25 (0.75)	0.00 (0–6.00)	0.11 (0.42)	0.00 (0–3.00)
Diagnostic services	10.42 (11.86)	7.00 (0–90.00)	7.42 (9.63)	5.00 (0–89.00)
Type of charges ($)
Primary care	338.18 (267.00)	274.00 (0–1,893.10)	322.34 (312.37)	222.50 (0–2,017.00)
Specialty care	646.37 (1,758.88)	128.00 (0–16,528.10)	329.41 (746.67)	0.00 (0–6,168.00)
Emergency department	550.93 (1,913.96)	0.00 (0–18,782.50)	256.35 (846.09)	0.00 (0–6,596.50)
Hospitalizations	5,360.35 (22,566.23)	0.00 (0–194,958.50)	2,547.00 (11,266.65)	0.00 (0–123,446.00)
Diagnostic services	1,413.30 (2,311.54)	532.00 (0–23,190.50)	886.30 (1,368.26)	390.50 (0–10,645.50)
Total charges	8,308.32 (24,811.19)	1,435.00 (49.5–203,234.50)	4,341.40 (12,575.57)	948.00 (0–134,788.50)

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Table 4.

Two-Part Regression Models for Utilization of Specialty Care Clinic and Charges Using Patient-Centeredness, Sex, Age, Education, Income, Obesity, Smoking, Alcohol Abuse, Mental and Physical Health Status as Explanatory Variables

Dependent Variable	Independent Variable^*	Utilization^†		Charges^‡
Dependent Variable	Independent Variable^*	Odds Ratio (95% CI)	P	SE	P	R²
Specialty Care Clinic (n = 260)	Female sex	1.636 (1.083–2.471)	.0192	−0.0127	.8427	0.1086
	Age	1.026 (1.012–1.040)	.0003	0.1168	.0653
	Education	1.005 (0.933–1.082)	.8972	−0.0052	.9348
	Income	1.020 (0.947–1.099)	.5944	0.0223	.7376
	Obesity	1.705 (1.157–2.514)	.0070	−0.0360	.5592
	Smoking	1.153 (0.756–1.757)	.5088	0.0187	.7684
	Alcohol abuse	2.210 (1.041–4.692)	.0391	−0.0533	.3932
	Mental health status	1.010 (0.994–1.026)	.2285	0.0810	.1962
	Physical health status	0.979 (0.963–0.996)	.0154	−0.1423	.0266
	Patient-centered care	0.966 (0.934–0.999)	.0417	−0.2239	.0005

↵* All independent variables are baseline measurements except for the patient centered care, which is averaged over 1 year of care.
↵† Utilization results were obtained by logistic regression models.
↵‡ Medical charges for specialty care are in log-transformed dollars, with mean 6.04 (SD, 1.24).
SE, standardized error.

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Table 5.

Standardized Estimates from Regression Equations in Which Total Medical Charges* are Explained by the Average Percentage of Patient-Centered Care Over the 1-Year Study Period, Controlling for Baseline Patient Sex, Age, Education, Income, Physical Health Status, Mental Health Status, Obesity, Alcohol Abuse, and Smoking (n = 494)

Dependent Variable	Independent Variables^†	SE	P	R²
Total charges (primary, specialty, and emergency care, hospitalizations and diagnostic services)	Female sex	0.1098	.0115	0.2142
	Age	0.2332	<.0001
	Education	−0.0121	.7803
	Income	−0.0119	.7878
	Physical health status	−0.2327	<.0001
	Mental health status	0.0023	.9564
	Obesity	0.0806	.0511
	Alcohol abuse	0.0405	.3317
	Smoking	0.0773	.0701
	Patient-centered care	−0.1575	.0002

↵* Total Medical Charges with mean 7.22 (SD = 1.59).
↵† All independent variables are baseline measurements, except for the patient centered care which is averaged over one year of care.
SE, standardized error.

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Table 6.

Standardized Estimates from Regression Equations in which Total Medical Charges* are Explained by the Average Percentage of Patient-Centered Care Over the 1-Year Study Period, for Female Compared to Male Patients Controlling for Baseline Patient Age, Education, Income, Physical Health Status, Mental Health Status, Obesity, Alcohol Abuse, and Smoking

Independent Variable^†	Women (n = 306)			Men (n = 188)
Independent Variable^†	SE	P	R²	SE	P	R²
Age	0.2339	<.0001	0.1547	0.2530	.0002	0.3118
Education	0.0351	.5370		−0.0672	.3248
Income	−0.0684	.2412		0.0781	.2535
Physical health status	−0.1647	.0043		−0.3460	<.0001
Mental health status	0.0178	.7480		−0.0263	.6822
Obesity	0.0764	.1622		0.0791	.2223
Alcohol abuse	0.0029	.9583		0.0621	.3356
Smoking	0.0838	.1453		0.0896	.1707
Patient-centered care	−0.1292	.0255		−0.1889	.0045

↵* Total medical charges are in log-transformed dollars, with mean 7.37 (SD, 1.51) for women and 6.97 (SD, 1.68) for men.
↵† All independent variables are baseline measurements except for the patient centered care, which is averaged over 1 year of care.
SE, standardized error.