DIAGNOSIS
AND
TREATMENT
Internists' Practices in Health Promotion and Disease Prevention A Survey J. Sanford Schwartz, MD; Charles E. Lewis, MD, ScD; Carolyn Clancy, MD; Monica S. Kinosian, MHS; Margaret H. Radany, MPP; and Jeffrey P. Koplan, MD, MPH
Objective: To estimate internists' use of disease prevention and health promotion activities, and to explore demographic, professional, behavioral, psychological, cognitive, and organizational factors associated with the use of such practices. Design: Mail survey. Setting and Subjects: A sample of 2610 members and fellows of the American College of Physicians (ACP) participated in the study. They engaged in patient care activities more than 20 hours per week and were stratified by gender and region. They lived in four geographic areas of the United States (Northeast, Southeast, Central, and West), comprising 21 ACP regions. Measurements: A questionnaire requesting background information as well as information about personal health; record keeping; use of immunizations (pneumococcal, influenza, tetanus, hepatitis B); use of screening tests and procedures for detecting cancer (breast examination, Papanicolaou smear, stool occult blood test) and other diseases (electrocardiograms, cholesterol level tests, chest radiographs); and behavioral counseling to promote health (in the areas of smoking, exercise, and alcohol and seat belt use). Main Results: Internists used effective preventive interventions less frequently and ineffective practices more frequently than experts recommend. Internists' use of health promotion and disease prevention activities is associated with habit, attitude, and a lack of adequate knowledge. Younger physician age, general internal medicine practice, and personal health promotion and disease prevention practices were strongly associated with more appropriate use of recommended practices (P < 0.01). Conclusions: Internists' use of disease prevention and health promotion activities falls short of expert recommendations. Programs to improve the delivery of preventive services might be aimed at improving physicians' personal health practices, might be directed toward patients, and might include the development of effective systems to remind physicians.
Annals of Internal Medicine. 1991;114:46-53. From the University of Pennsylvania, Philadelphia, Pennsylvania; the University of California at Los Angeles, Los Angeles, California; the Medical College of Virginia, Richmond, Virginia; the American College of Physicians, Philadelphia, Pennsylvania; and the Centers for Disease Control, Atlanta, Georgia. For current author addresses, see end of text. 46
A great deal of morbidity and mortality in adults is, to some degree, preventable (1). A major opportunity to prevent disease and to promote health lies in physicianpatient encounters as well as in population-based public health programs. Physicians can improve public health by counseling patients about the nature and value of health promotion and disease prevention behaviors, assisting patients in adopting recommended behaviors, engaging in selected disease screening activities, and administering vaccines to prevent specific infectious diseases. Internists provide much of the medical care received by adults in the United States. The degree to which internists adhere to expert recommendations in their disease prevention and health promotion practices has not been adequately studied, and the reasons for observed deviations from recommended guidelines are not well understood. Previous studies of physicians' preventive practices have usually evaluated physician performance in one of three categories: use of immunizations, compliance with established guidelines for screening, or self-reported use of counseling about health habits. In general, according to self-report (2-28) or documentation (12, 29-59), physicians have been found to engage in health promotion activities less frequently than is recommended by expert guidelines. Some important limitations of earlier studies, however, include relatively small sample sizes (none included more than 500 physicians), little or no information about physician characteristics or practice organization, and no data on geographic variations. Because most studies have examined only a portion of all preventive services recommended for adults, data about the correlation among various components of physicians' health promotion and disease prevention activities are few. In addition, no study has examined the extent to which physicians' personal health practices correlate with their practice behaviors. These limitations raise many as yet unanswered questions about the extent of physicians' use of preventive services. The objectives of this project were to determine the extent of internists' use of disease prevention and health promotion activities and to explore factors that might help to explain observed practice patterns. Hypotheses were developed after a review of the published literature on physicians' health promotion and disease prevention activities. The study examined internists' use of selected immunizations, cancer screening tests and procedures, and health promotion counseling activities. Specifically, the study sought to determine:
1 January 1991 • Annals of Internal Medicine • Volume 114 • Number 1
Downloaded From: http://annals.org/ by a University of California San Diego User on 12/13/2016
1. I n t e r n i s t s ' reported use of selected health p r o m o tion and disease prevention activities and the types of patients to w h o m such activities are provided. 2. I n t e r n i s t s ' attitudes t o w a r d selected health p r o m o tion and disease prevention activities. 3. I n t e r n i s t s ' knowledge of the safety, efficacy, c o s t s , and benefits of selected health promotion and disease prevention activities. 4. I n t e r n i s t s ' knowledge of expert r e c o m m e n d a t i o n s about specific health promotion and disease prevention activities. 5. T h e difference b e t w e e n generalists' and specialists' use of health promotion and disease prevention activities. 6. T h e degree to which internists' subspecialties influence their use of health promotion and disease prevention activities. 7. T h e degree to which r e s p o n d e n t s ' self-reported health p r o m o t i o n and disease prevention activities comply with nationally r e c o m m e n d e d s t a n d a r d s . 8. T h e relation a m o n g internists' use of health promotion and disease prevention activities, knowledge, attitudes, personal health practices, and selected sociod e m o g r a p h i c factors.
Methods A mail survey of a stratified sample of practicing internists who were members and fellows of the American College of Physicians (ACP) was conducted between 1 April 1987 and 31 August 1987. The survey requested background information as well as information on personal health and record keeping. The survey also asked about preventive practices, including the use of immunizations (pneumococcal, influenza, tetanus, hepatitis B), cancer screening tests and procedures (breast examination, Papanicolaou smear, stool occult blood test), and other selected screening tests (electrocardiograms, cholesterol level tests, chest radiographs). In addition, the survey asked about counseling practices in the areas of smoking, exercise, and seat belt and alcohol use. The original sample consisted of 2610 internists who were randomly selected from among the approximately 18 000 ACP members and fellows living in four geographic areas (Northeast, Southeast, Central, and West) of the United States, comprising 21 ACP regions. The sample was stratified on the basis of gender. Because women comprise only 8.5% of ACP members and fellows in the four geographic areas studied, women in the study areas were over-sampled to include 40% of all women members and fellows. In comparison, the sampling fraction of male members and fellows within the four areas was 13.6%. This sampling assured sufficient statistical power to permit a comparison of male and female respondents. To be eligible to complete the survey, respondents had to have completed their postgraduate training (residency and fellowship) at least 1 year before the survey was conducted and to engage in clinical practice at least 20 hours per week. An extensive effort was made to maximize the response rate. The survey was publicized by the ACP, before it was mailed, through notices and articles in Annals of Internal Medicine, ACP Observer, and ACP governor's newsletters. In the initial mailing, the survey was accompanied by a cover letter from the ACP president, providing the names and telephone numbers of the co-principal investigators and the ACP's "800" telephone number as well as the name of the person coordinating the survey at the College. Subjects who did not return the survey within 3 weeks of the mailing were mailed a second survey along with a cover letter from the physician's ACP regional governor. If no response was received within 3 weeks of the second mailing, ACP governors or their designates telephoned the subject to determine whether he or she was inter-
ested in completing the survey. If the subject indicated a willingness to complete the survey, a third survey was mailed. The recipients who returned their surveys because they were trainees (residents or fellows) or were not currently in practice were randomly replaced with persons from the original sample population. Respondents who returned their surveys because they engaged in patient care less than 20 hours per week or because they were not interested in completing the survey were not replaced. Demographic and practice-related variables from the ACP's data set were obtained for a 30% random sample of nonrespondents to permit a comparison of respondents with nonrespondents. The survey's sample size was calculated to permit detection of differences of at least 10% (alpha = 0.05, beta = 0.90, assuming a response rate of 75%) in the responses of specialty and gender subgroups. The data were weighted to adjust for the oversampling of women to obtain frequencies and descriptive statistics for each survey item. The reported frequencies and percentages were determined on the basis of the responses of the internists who answered each question. Responses about the use of individual health promotion and disease prevention practices; record keeping; sources of information about health promotion and disease prevention practices and their importance to the respondent; knowledge of specific health promotion and disease prevention practices; and intentions, perceptions, and attitudes were examined by cross-tabulation with respondent age, gender, geographic location, practice structure, and board certification. The appropriateness of these practices was determined by comparing respondents' reported practices with those recommended by expert-derived guidelines (specifically, those of the American Cancer Society, the American College of Physicians, the American Heart Association, the Canadian Task Force, and the Centers for Disease Control). When these expert guidelines differed from one another, we accepted the least stringent standard as representing appropriate care, thus biasing the data toward overestimating appropriate behavior. General internists were also compared with subspecialists. Because there is no uniformly accepted definition of a general internist, general internal medicine and subspecialty status were analyzed in two ways. First, the sample was divided into three components: internists who practiced only general internal medicine; those who practiced both general internal medicine and subspecialty medicine; and those who engaged only in subspecialty practice. A second analysis split the respondents according to whether general internal medicine composed more or less than 50% of the respondent's practice. The results of these analyses, despite their use of different definitions, were similar. We present results that are based on the latter definition. One set of hypotheses concerned whether specialists engage in health promotion and disease prevention activities that are related to their subspecialty more frequently than do general internists. To test these hypotheses, additional subanalyses were done of cardiology and pulmonary specialists and their practice of smoking cessation counseling; of cardiology, pulmonary, and infectious disease specialists and their use of pneumococcal and influenza vaccine; and of oncology and gastroenterology specialists and their use of screening tests for cancer (mammography and Papanicolaou smear for oncologists and stool occult blood testing and sigmoidoscopy for both oncologists and gastroenterologists). Similarly, subanalyses were done to determine whether male and female internists differed in health promotion and disease prevention practices, especially in the use of tests and procedures that are used only for female patients (Papanicolaou smear, manual breast examination, and mammography). Descriptive analyses were done for all respondents and for relevant subsets of respondents on all survey items. Bivariate cross-tabulations by respondent age, subspecialty, gender, geographic location, board certification, and type of practice (solo or group) were examined for statistical significance using the Student /-test for continuous variables and chi-square analysis (with continuity correction where appropriate) for discrete variables. Analysis of covariance and logistic regression were done on the unweighted data to adjust the analyses for the effects of respondent age, gender, percent general internal
1 January 1991 • Annals of Internal Medicine
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• Volume 114 • Number 1
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Table 1. Demographic and Practice-Related istics of Respondents Characteristic Age,y 56 Men Board certification Internal medicine Subspecialty Percent general internal medicine practice 100% Mixed 0% Medical school affiliation Full-time Volunteer None or other Group practice Number of patients seen per week 76 Time spent seeing patients, % 100 90-99 75-89
—% 43 80
44 94
44 93
93 62 88
13 70 78
53 65 83
son, only 45% to 55% of respondents reported using these vaccines in nursing home patients. Influenza vaccine was more widely used than pneumococcal vaccine, even though respondents reported similar perceived levels of safety and efficacy for the two vaccines. Respondents reported routinely giving hepatitis B vaccine to 46% of their patients who were physicians and nurses. Respondents reported that the Centers for Disease Control (CDC) recommendations and the ACP Guide for Adult Immunization were their most important sources of information about vaccine use. However, 10% thought that CDC recommendations were too controversial, too complex, or changed too frequently, and almost 20% of respondents stated that they did not know the CDC recommendations for the use of pneumococcal vaccine. Respondents reported that the most important factors, other than expert guidelines, in deciding to administer an immunization were the vaccine's perceived safety and efficacy. Patient reluctance to receive a vaccine because of discomfort, fear of side effects, or inconvenience, and difficulty on the part of the physician in remembering to administer a desired vaccine were perceived as important barriers to more widespread use of vaccines. Screening for Cancer Respondents' recommended use of appropriate disease screening activities in asymptomatic 50-year-old patients was inconsistent (Table 4). Almost all respondents recommended annual manual breast examinations on such patients. Ninety percent of respondents recommended obtaining Papanicolaou smears of the cervix and stool occult blood tests for patients 50 years of age or older. Seventy-six percent of respondents recommended obtaining annual cervical Papanicolaou smears on such patients; an additional 22% recommended obtaining Papanicolaou smears at 3- to 5-year intervals. Approximately 75% of respondents recommended obtaining serum cholesterol measurements for and doing sigmoidoscopy and mammography at least every 3 to 5 years in older patients. Only 50% recommended doing annual mammography on 50-year-old asymptomatic women. Screening chest radiographs and electrocardiograms were recommended regularly in at least 55% of older, asymptomatic patients. The Papanicolaou smear was perceived to be the most effective of the three cancer screening tests examined (Table 5). Mammography was thought to be a
somewhat more effective cancer screening test than manual breast examination, stool occult blood testing, and sigmoidoscopy. The effectiveness of mammography and stool occult blood testing in detecting asymptomatic disease (their sensitivity) and in consequently improving survival were the most important factors in doing cancer screening tests. Cost, the frequency of false-positive results, and patient requests were " v e r y " or "somewhat" important factors for approximately 75% of respondents. Approximately 10% of respondents considered patient reluctance, the risk of the tests, and the physician time required to do the test to be important barriers to use of these tests. Respondents' knowledge of the risk factors for cervical, breast, and colon carcinoma was uneven. Eightysix percent of respondents correctly identified the risk factors for breast cancer; only 60% and 80% of respondents correctly identified the major risk factors for cervical and colon cancer, respectively. Twenty-three percent of respondents incorrectly identified benign conditions (chronic constipation and irritable colon) as risk factors for colon cancer. American Cancer Society and ACP recommendations were reported to be the most important sources of information about screening for cancer, with reported levels of acceptance and knowledge similar to those of the CDC and ACP immunization recommendations. Personal Health Respondents' personal health behaviors are summarized in Table 6. Fully 50% of respondents did not have a personal physician. However, older physicians were more likely to have had a recent physical examination and to have a personal physician. Fifty-five percent of respondents had not had a physical examination within the previous 3 years. The majority (64%) of physicians characterized their own health as better than average. The typical respondent had not missed any work because of illness in the year before the survey. More than 90% of respondents reported being immunized against tetanus. Approximately 40% of respondents reported having received hepatitis B and influenza vaccine. Only 9% reported having received pneumococcal vaccine. About 74% of respondents 50 years of age or older had had a test for occult blood in the stool; 58% had had sigmoidoscopy. Virtually all women reTable 3. Information on Health Promotion and Disease Prevention Routinely Collected by Internists Activity, Test, or Procedure Smoking Alcohol use Occupation Stool occult blood test Papanicolaou smear Exercise Diet Mammography Sexual activities Immunizations Seat belt use
1 January 1991 • Annals of Internal Medicine
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Percentage of Patients for Whom Information Is Collected 98 94 88 76 71 67 66 59 40 42 11
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Table 4. Internists' Recommended Use of Routine Disease Screening Tests and Procedures for Asymptomatic 50-Year-Old Patients Test or Procedure
Done Annually
Done Every 3 to 5 Years
% Breast examination Stool occult blood test Papanicolaou smear Mammography Cholesterol test Electrocardiogram Sigmoidoscopy Chest roentgenogram
98 90 77 50 52 26 13 11
1 7 22 41 35 38 62 34
spondents reported having received a Papanicolaou smear, 26% within the past year and 84% within the previous 3 years. Almost all women respondents reported doing manual breast self-examination, although only half did so monthly. Factors Related to Practicing Clinical Preventive Medicine Younger physicians, general internists, board-certified internists, physicians practicing in groups, and women internists were more likely to engage in more appropriate use of selected health promotion and disease prevention practices. However, simultaneous adjustment for each of these factors revealed that younger physician age and general internal medicine practice were most strongly associated with more appropriate use of recommended health promotion and disease prevention practices. Except for increased knowledge about the risk factors for cervical cancer and teaching breast self-examination techniques more frequently to patients, the improved practices of women internists primarily resulted from their younger age and their greater tendency to be general internists. Similarly, subspecialists exhibited improved compliance relative to other subspecialists with recommended health promotion and disease prevention practices only for those practices directly related to their subspecialty. These high levels of compliance did not carry over to other health promotion and disease prevention practices, even within the same class of practices (for example, within the class of immunization or of cancer screening). Even for practices related to their own subspecialty, subspecialists' level of appropriate use often was not as high as that of general internists. Group practice (as compared with solo practice) and board certification were weakly associated with more appropriate health promotion and disease prevention activities, but most of these observed effects disappeared once the data were adjusted for the influence of physician age and proportion of general internal medicine practice. The relation between respondents' personal health promotion and disease prevention practices and their propensity to offer the same services to their patients was strong (P < 0.01). This relation was present for all 50
three classes of health promotion and disease prevention activities that were studied (immunizations, screening, and behavioral factors [smoking, exercise, and alcohol and seat belt use]). No significant difference was found between the respondents and the 30% nonrespondent sample in gender, age, year of medical school graduation, or geographic region. Nonrespondents were less likely than respondents to be board certified (P < 0.01). Discussion This survey represents the largest national survey of a broad range of health promotion and disease prevention practices conducted among actively practicing internists. The survey addressed not only the frequency of use of selected health promotion and disease prevention practices, but also examined factors thought to possibly influence the use of such practices, such as physician age and gender; proportion of general internal medicine practice; specialty; practice organization; academic appointment; personal health habits and practices; knowledge; attitudes; sources of information; perceived counseling skills and effectiveness; perceived incentives and barriers; and perceived safety, efficacy, and benefit of practices. A range of immunization and screening practices and health promotion and behavioral counseling activities was examined. Before this survey, the only information on physicians' health promotion and disease prevention practices either was obtained from providers within a specific geographic region or practice setting or focused on a single aspect or component of health promotion and disease prevention practices. Studies of beliefs and attitudes about and actual practice of health counseling and health promotion, conducted among primary care physicians in western Massachusetts and in Maryland, noted poor compliance with national expert-derived recommendations (5, 7, 61). Similar results were found in studies of cancer screening practices conducted in Quebec (11, 12, 15) and in the United States (13, 19) and in a study of treatment and referrals for cigarette smoking, obesity, and sedentary lifestyle conducted among a small, nationwide sample of family practitioners (62). Previous studies of physicians' personal health behaviors have been similarly limited. The health habits of academic internists at the University of California, Los Angeles, but not their patient care practice patterns, were examined (63, 64). Lewis and coworkers (8) developed and tested a model of physician counseling
Table 5. The Effectiveness of Cancer Screening as Perceived by Physicians Test
Tests,
Moderately Effective
Very Effective
AND
TREATMENT
Internists' Practices in Health Promotion and Disease Prevention A Survey J. Sanford Schwartz, MD; Charles E. Lewis, MD, ScD; Carolyn Clancy, MD; Monica S. Kinosian, MHS; Margaret H. Radany, MPP; and Jeffrey P. Koplan, MD, MPH
Objective: To estimate internists' use of disease prevention and health promotion activities, and to explore demographic, professional, behavioral, psychological, cognitive, and organizational factors associated with the use of such practices. Design: Mail survey. Setting and Subjects: A sample of 2610 members and fellows of the American College of Physicians (ACP) participated in the study. They engaged in patient care activities more than 20 hours per week and were stratified by gender and region. They lived in four geographic areas of the United States (Northeast, Southeast, Central, and West), comprising 21 ACP regions. Measurements: A questionnaire requesting background information as well as information about personal health; record keeping; use of immunizations (pneumococcal, influenza, tetanus, hepatitis B); use of screening tests and procedures for detecting cancer (breast examination, Papanicolaou smear, stool occult blood test) and other diseases (electrocardiograms, cholesterol level tests, chest radiographs); and behavioral counseling to promote health (in the areas of smoking, exercise, and alcohol and seat belt use). Main Results: Internists used effective preventive interventions less frequently and ineffective practices more frequently than experts recommend. Internists' use of health promotion and disease prevention activities is associated with habit, attitude, and a lack of adequate knowledge. Younger physician age, general internal medicine practice, and personal health promotion and disease prevention practices were strongly associated with more appropriate use of recommended practices (P < 0.01). Conclusions: Internists' use of disease prevention and health promotion activities falls short of expert recommendations. Programs to improve the delivery of preventive services might be aimed at improving physicians' personal health practices, might be directed toward patients, and might include the development of effective systems to remind physicians.
Annals of Internal Medicine. 1991;114:46-53. From the University of Pennsylvania, Philadelphia, Pennsylvania; the University of California at Los Angeles, Los Angeles, California; the Medical College of Virginia, Richmond, Virginia; the American College of Physicians, Philadelphia, Pennsylvania; and the Centers for Disease Control, Atlanta, Georgia. For current author addresses, see end of text. 46
A great deal of morbidity and mortality in adults is, to some degree, preventable (1). A major opportunity to prevent disease and to promote health lies in physicianpatient encounters as well as in population-based public health programs. Physicians can improve public health by counseling patients about the nature and value of health promotion and disease prevention behaviors, assisting patients in adopting recommended behaviors, engaging in selected disease screening activities, and administering vaccines to prevent specific infectious diseases. Internists provide much of the medical care received by adults in the United States. The degree to which internists adhere to expert recommendations in their disease prevention and health promotion practices has not been adequately studied, and the reasons for observed deviations from recommended guidelines are not well understood. Previous studies of physicians' preventive practices have usually evaluated physician performance in one of three categories: use of immunizations, compliance with established guidelines for screening, or self-reported use of counseling about health habits. In general, according to self-report (2-28) or documentation (12, 29-59), physicians have been found to engage in health promotion activities less frequently than is recommended by expert guidelines. Some important limitations of earlier studies, however, include relatively small sample sizes (none included more than 500 physicians), little or no information about physician characteristics or practice organization, and no data on geographic variations. Because most studies have examined only a portion of all preventive services recommended for adults, data about the correlation among various components of physicians' health promotion and disease prevention activities are few. In addition, no study has examined the extent to which physicians' personal health practices correlate with their practice behaviors. These limitations raise many as yet unanswered questions about the extent of physicians' use of preventive services. The objectives of this project were to determine the extent of internists' use of disease prevention and health promotion activities and to explore factors that might help to explain observed practice patterns. Hypotheses were developed after a review of the published literature on physicians' health promotion and disease prevention activities. The study examined internists' use of selected immunizations, cancer screening tests and procedures, and health promotion counseling activities. Specifically, the study sought to determine:
1 January 1991 • Annals of Internal Medicine • Volume 114 • Number 1
Downloaded From: http://annals.org/ by a University of California San Diego User on 12/13/2016
1. I n t e r n i s t s ' reported use of selected health p r o m o tion and disease prevention activities and the types of patients to w h o m such activities are provided. 2. I n t e r n i s t s ' attitudes t o w a r d selected health p r o m o tion and disease prevention activities. 3. I n t e r n i s t s ' knowledge of the safety, efficacy, c o s t s , and benefits of selected health promotion and disease prevention activities. 4. I n t e r n i s t s ' knowledge of expert r e c o m m e n d a t i o n s about specific health promotion and disease prevention activities. 5. T h e difference b e t w e e n generalists' and specialists' use of health promotion and disease prevention activities. 6. T h e degree to which internists' subspecialties influence their use of health promotion and disease prevention activities. 7. T h e degree to which r e s p o n d e n t s ' self-reported health p r o m o t i o n and disease prevention activities comply with nationally r e c o m m e n d e d s t a n d a r d s . 8. T h e relation a m o n g internists' use of health promotion and disease prevention activities, knowledge, attitudes, personal health practices, and selected sociod e m o g r a p h i c factors.
Methods A mail survey of a stratified sample of practicing internists who were members and fellows of the American College of Physicians (ACP) was conducted between 1 April 1987 and 31 August 1987. The survey requested background information as well as information on personal health and record keeping. The survey also asked about preventive practices, including the use of immunizations (pneumococcal, influenza, tetanus, hepatitis B), cancer screening tests and procedures (breast examination, Papanicolaou smear, stool occult blood test), and other selected screening tests (electrocardiograms, cholesterol level tests, chest radiographs). In addition, the survey asked about counseling practices in the areas of smoking, exercise, and seat belt and alcohol use. The original sample consisted of 2610 internists who were randomly selected from among the approximately 18 000 ACP members and fellows living in four geographic areas (Northeast, Southeast, Central, and West) of the United States, comprising 21 ACP regions. The sample was stratified on the basis of gender. Because women comprise only 8.5% of ACP members and fellows in the four geographic areas studied, women in the study areas were over-sampled to include 40% of all women members and fellows. In comparison, the sampling fraction of male members and fellows within the four areas was 13.6%. This sampling assured sufficient statistical power to permit a comparison of male and female respondents. To be eligible to complete the survey, respondents had to have completed their postgraduate training (residency and fellowship) at least 1 year before the survey was conducted and to engage in clinical practice at least 20 hours per week. An extensive effort was made to maximize the response rate. The survey was publicized by the ACP, before it was mailed, through notices and articles in Annals of Internal Medicine, ACP Observer, and ACP governor's newsletters. In the initial mailing, the survey was accompanied by a cover letter from the ACP president, providing the names and telephone numbers of the co-principal investigators and the ACP's "800" telephone number as well as the name of the person coordinating the survey at the College. Subjects who did not return the survey within 3 weeks of the mailing were mailed a second survey along with a cover letter from the physician's ACP regional governor. If no response was received within 3 weeks of the second mailing, ACP governors or their designates telephoned the subject to determine whether he or she was inter-
ested in completing the survey. If the subject indicated a willingness to complete the survey, a third survey was mailed. The recipients who returned their surveys because they were trainees (residents or fellows) or were not currently in practice were randomly replaced with persons from the original sample population. Respondents who returned their surveys because they engaged in patient care less than 20 hours per week or because they were not interested in completing the survey were not replaced. Demographic and practice-related variables from the ACP's data set were obtained for a 30% random sample of nonrespondents to permit a comparison of respondents with nonrespondents. The survey's sample size was calculated to permit detection of differences of at least 10% (alpha = 0.05, beta = 0.90, assuming a response rate of 75%) in the responses of specialty and gender subgroups. The data were weighted to adjust for the oversampling of women to obtain frequencies and descriptive statistics for each survey item. The reported frequencies and percentages were determined on the basis of the responses of the internists who answered each question. Responses about the use of individual health promotion and disease prevention practices; record keeping; sources of information about health promotion and disease prevention practices and their importance to the respondent; knowledge of specific health promotion and disease prevention practices; and intentions, perceptions, and attitudes were examined by cross-tabulation with respondent age, gender, geographic location, practice structure, and board certification. The appropriateness of these practices was determined by comparing respondents' reported practices with those recommended by expert-derived guidelines (specifically, those of the American Cancer Society, the American College of Physicians, the American Heart Association, the Canadian Task Force, and the Centers for Disease Control). When these expert guidelines differed from one another, we accepted the least stringent standard as representing appropriate care, thus biasing the data toward overestimating appropriate behavior. General internists were also compared with subspecialists. Because there is no uniformly accepted definition of a general internist, general internal medicine and subspecialty status were analyzed in two ways. First, the sample was divided into three components: internists who practiced only general internal medicine; those who practiced both general internal medicine and subspecialty medicine; and those who engaged only in subspecialty practice. A second analysis split the respondents according to whether general internal medicine composed more or less than 50% of the respondent's practice. The results of these analyses, despite their use of different definitions, were similar. We present results that are based on the latter definition. One set of hypotheses concerned whether specialists engage in health promotion and disease prevention activities that are related to their subspecialty more frequently than do general internists. To test these hypotheses, additional subanalyses were done of cardiology and pulmonary specialists and their practice of smoking cessation counseling; of cardiology, pulmonary, and infectious disease specialists and their use of pneumococcal and influenza vaccine; and of oncology and gastroenterology specialists and their use of screening tests for cancer (mammography and Papanicolaou smear for oncologists and stool occult blood testing and sigmoidoscopy for both oncologists and gastroenterologists). Similarly, subanalyses were done to determine whether male and female internists differed in health promotion and disease prevention practices, especially in the use of tests and procedures that are used only for female patients (Papanicolaou smear, manual breast examination, and mammography). Descriptive analyses were done for all respondents and for relevant subsets of respondents on all survey items. Bivariate cross-tabulations by respondent age, subspecialty, gender, geographic location, board certification, and type of practice (solo or group) were examined for statistical significance using the Student /-test for continuous variables and chi-square analysis (with continuity correction where appropriate) for discrete variables. Analysis of covariance and logistic regression were done on the unweighted data to adjust the analyses for the effects of respondent age, gender, percent general internal
1 January 1991 • Annals of Internal Medicine
Downloaded From: http://annals.org/ by a University of California San Diego User on 12/13/2016
• Volume 114 • Number 1
47
Table 1. Demographic and Practice-Related istics of Respondents Characteristic Age,y 56 Men Board certification Internal medicine Subspecialty Percent general internal medicine practice 100% Mixed 0% Medical school affiliation Full-time Volunteer None or other Group practice Number of patients seen per week 76 Time spent seeing patients, % 100 90-99 75-89
—% 43 80
44 94
44 93
93 62 88
13 70 78
53 65 83
son, only 45% to 55% of respondents reported using these vaccines in nursing home patients. Influenza vaccine was more widely used than pneumococcal vaccine, even though respondents reported similar perceived levels of safety and efficacy for the two vaccines. Respondents reported routinely giving hepatitis B vaccine to 46% of their patients who were physicians and nurses. Respondents reported that the Centers for Disease Control (CDC) recommendations and the ACP Guide for Adult Immunization were their most important sources of information about vaccine use. However, 10% thought that CDC recommendations were too controversial, too complex, or changed too frequently, and almost 20% of respondents stated that they did not know the CDC recommendations for the use of pneumococcal vaccine. Respondents reported that the most important factors, other than expert guidelines, in deciding to administer an immunization were the vaccine's perceived safety and efficacy. Patient reluctance to receive a vaccine because of discomfort, fear of side effects, or inconvenience, and difficulty on the part of the physician in remembering to administer a desired vaccine were perceived as important barriers to more widespread use of vaccines. Screening for Cancer Respondents' recommended use of appropriate disease screening activities in asymptomatic 50-year-old patients was inconsistent (Table 4). Almost all respondents recommended annual manual breast examinations on such patients. Ninety percent of respondents recommended obtaining Papanicolaou smears of the cervix and stool occult blood tests for patients 50 years of age or older. Seventy-six percent of respondents recommended obtaining annual cervical Papanicolaou smears on such patients; an additional 22% recommended obtaining Papanicolaou smears at 3- to 5-year intervals. Approximately 75% of respondents recommended obtaining serum cholesterol measurements for and doing sigmoidoscopy and mammography at least every 3 to 5 years in older patients. Only 50% recommended doing annual mammography on 50-year-old asymptomatic women. Screening chest radiographs and electrocardiograms were recommended regularly in at least 55% of older, asymptomatic patients. The Papanicolaou smear was perceived to be the most effective of the three cancer screening tests examined (Table 5). Mammography was thought to be a
somewhat more effective cancer screening test than manual breast examination, stool occult blood testing, and sigmoidoscopy. The effectiveness of mammography and stool occult blood testing in detecting asymptomatic disease (their sensitivity) and in consequently improving survival were the most important factors in doing cancer screening tests. Cost, the frequency of false-positive results, and patient requests were " v e r y " or "somewhat" important factors for approximately 75% of respondents. Approximately 10% of respondents considered patient reluctance, the risk of the tests, and the physician time required to do the test to be important barriers to use of these tests. Respondents' knowledge of the risk factors for cervical, breast, and colon carcinoma was uneven. Eightysix percent of respondents correctly identified the risk factors for breast cancer; only 60% and 80% of respondents correctly identified the major risk factors for cervical and colon cancer, respectively. Twenty-three percent of respondents incorrectly identified benign conditions (chronic constipation and irritable colon) as risk factors for colon cancer. American Cancer Society and ACP recommendations were reported to be the most important sources of information about screening for cancer, with reported levels of acceptance and knowledge similar to those of the CDC and ACP immunization recommendations. Personal Health Respondents' personal health behaviors are summarized in Table 6. Fully 50% of respondents did not have a personal physician. However, older physicians were more likely to have had a recent physical examination and to have a personal physician. Fifty-five percent of respondents had not had a physical examination within the previous 3 years. The majority (64%) of physicians characterized their own health as better than average. The typical respondent had not missed any work because of illness in the year before the survey. More than 90% of respondents reported being immunized against tetanus. Approximately 40% of respondents reported having received hepatitis B and influenza vaccine. Only 9% reported having received pneumococcal vaccine. About 74% of respondents 50 years of age or older had had a test for occult blood in the stool; 58% had had sigmoidoscopy. Virtually all women reTable 3. Information on Health Promotion and Disease Prevention Routinely Collected by Internists Activity, Test, or Procedure Smoking Alcohol use Occupation Stool occult blood test Papanicolaou smear Exercise Diet Mammography Sexual activities Immunizations Seat belt use
1 January 1991 • Annals of Internal Medicine
Downloaded From: http://annals.org/ by a University of California San Diego User on 12/13/2016
Percentage of Patients for Whom Information Is Collected 98 94 88 76 71 67 66 59 40 42 11
• Volume 114 • Number 1
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Table 4. Internists' Recommended Use of Routine Disease Screening Tests and Procedures for Asymptomatic 50-Year-Old Patients Test or Procedure
Done Annually
Done Every 3 to 5 Years
% Breast examination Stool occult blood test Papanicolaou smear Mammography Cholesterol test Electrocardiogram Sigmoidoscopy Chest roentgenogram
98 90 77 50 52 26 13 11
1 7 22 41 35 38 62 34
spondents reported having received a Papanicolaou smear, 26% within the past year and 84% within the previous 3 years. Almost all women respondents reported doing manual breast self-examination, although only half did so monthly. Factors Related to Practicing Clinical Preventive Medicine Younger physicians, general internists, board-certified internists, physicians practicing in groups, and women internists were more likely to engage in more appropriate use of selected health promotion and disease prevention practices. However, simultaneous adjustment for each of these factors revealed that younger physician age and general internal medicine practice were most strongly associated with more appropriate use of recommended health promotion and disease prevention practices. Except for increased knowledge about the risk factors for cervical cancer and teaching breast self-examination techniques more frequently to patients, the improved practices of women internists primarily resulted from their younger age and their greater tendency to be general internists. Similarly, subspecialists exhibited improved compliance relative to other subspecialists with recommended health promotion and disease prevention practices only for those practices directly related to their subspecialty. These high levels of compliance did not carry over to other health promotion and disease prevention practices, even within the same class of practices (for example, within the class of immunization or of cancer screening). Even for practices related to their own subspecialty, subspecialists' level of appropriate use often was not as high as that of general internists. Group practice (as compared with solo practice) and board certification were weakly associated with more appropriate health promotion and disease prevention activities, but most of these observed effects disappeared once the data were adjusted for the influence of physician age and proportion of general internal medicine practice. The relation between respondents' personal health promotion and disease prevention practices and their propensity to offer the same services to their patients was strong (P < 0.01). This relation was present for all 50
three classes of health promotion and disease prevention activities that were studied (immunizations, screening, and behavioral factors [smoking, exercise, and alcohol and seat belt use]). No significant difference was found between the respondents and the 30% nonrespondent sample in gender, age, year of medical school graduation, or geographic region. Nonrespondents were less likely than respondents to be board certified (P < 0.01). Discussion This survey represents the largest national survey of a broad range of health promotion and disease prevention practices conducted among actively practicing internists. The survey addressed not only the frequency of use of selected health promotion and disease prevention practices, but also examined factors thought to possibly influence the use of such practices, such as physician age and gender; proportion of general internal medicine practice; specialty; practice organization; academic appointment; personal health habits and practices; knowledge; attitudes; sources of information; perceived counseling skills and effectiveness; perceived incentives and barriers; and perceived safety, efficacy, and benefit of practices. A range of immunization and screening practices and health promotion and behavioral counseling activities was examined. Before this survey, the only information on physicians' health promotion and disease prevention practices either was obtained from providers within a specific geographic region or practice setting or focused on a single aspect or component of health promotion and disease prevention practices. Studies of beliefs and attitudes about and actual practice of health counseling and health promotion, conducted among primary care physicians in western Massachusetts and in Maryland, noted poor compliance with national expert-derived recommendations (5, 7, 61). Similar results were found in studies of cancer screening practices conducted in Quebec (11, 12, 15) and in the United States (13, 19) and in a study of treatment and referrals for cigarette smoking, obesity, and sedentary lifestyle conducted among a small, nationwide sample of family practitioners (62). Previous studies of physicians' personal health behaviors have been similarly limited. The health habits of academic internists at the University of California, Los Angeles, but not their patient care practice patterns, were examined (63, 64). Lewis and coworkers (8) developed and tested a model of physician counseling
Table 5. The Effectiveness of Cancer Screening as Perceived by Physicians Test
Tests,
Moderately Effective
Very Effective
