Ochs-13-03-29 367.374

The Ochsner Journal 13:367–374, 2013Ó Academic Division of Ochsner Clinic Foundation Patient Tobacco Use, Quit Attempts, and Perceptions of Healthcare Provider Practices in a Safety-Net Healthcare System Sarah Moody-Thomas, PhD,*  Michael D. Celestin, Jr., MA, CHES, CTTS,* Tung-Sung Tseng, DrPH, MS, CHES/MCHES,* Ronald Horswell, PhDà *School of Public Health and  Stanley S. Scott Cancer Center, Louisiana State University Health Sciences Center, New Orleans, LA àPennington Biomedical Research Center, Baton Rouge, LA Results: Patient reports indicated that provider adherence to the 5A clinical protocol increased from 2004 to 2010.
Background: Although smoking rates in the United States (US) Significant (P<0.001) improvements were observed for theassess (39 are high, healthcare systems and clinicians can increase % vs 72%), assist (24% vs 76%), and arrange (8% vs 31%) treatment variables. Patient-reported quit cessation rates through application of the US Public Health attempts increased, along with awareness of cessation Service tobacco treatment guideline (2000, 2008). In primary services (from 19% to 70%, P<0.001), while use of cessation care settings, however, guideline implementation remains low.
medications decreased (from 23% to 5%, P<0.002).
This report presents the results from an assessment of patient Conclusion: Following implementation of the guideline, tobacco use, quit attempts, and perceptions of provider significant improvements were noted in patient reports of treatment before (2004) and after (2010) guideline implemen- provider treatment and awareness of cessation services.
Methods: By use of a systems approach, the LouisianaTobacco Control Initiative integrated evidence-based treatmentof tobacco use into patient care practices in Louisiana's public hospital system. This prospective study, designed to collect Tobacco use continues to lead the nation as a data at 2 time points for the purpose of evaluating the effect of preventable cause of morbidity and mortality.1 De- the 5A protocol (ask, advise, assess, assist, and arrange), spite reductions over the past 3 decades in smoking included 571 and 889 adult patients selected from primary among the nation's general population,2 rates of care clinics in 2004 and 2010, respectively. Chi-square tobacco use remain high among low-income, less- analyses determined differences between survey administra- educated, minority, and under- and uninsured tions, along with direct standardization of weighted rates to groups.3 Louisiana's smoking prevalence (22%) is control for confounding factors.
higher than the national average (17%).4 Nationwide,smoking rates vary by insurance coverage: 16% ofthose covered by private insurance smoke, compared Address correspondence to to 30% of public insurance enrollees (Medicaid and Sarah Moody-Thomas, PhD Medicare) and 32% of uninsured residents.5 In School of Public Health and Stanley S. Scott Cancer Center Louisiana, a large proportion (25%) of residents is Louisiana State University Health Sciences Center uninsured; 34% of these smoke.6 2020 Gravier St.
Healthcare providers and delivery systems can New Orleans, LA 70112 impact population-level cessation rates through im- Tel: (504) 568-6038 plementation of the US Public Health Service Fax: (504) 568-5911 (USPHS) clinical practice guideline (CPG) Treating Email: sthoma@lsuhsc.edu Tobacco Use and Dependence: 2008 Update thatincludes the 5A protocol: (1) ask about tobacco use, Keywords: Guideline adherence, physician's practice patterns, (2) advise all identified smokers to quit, (3) assess smoking cessation smokers' willingness to quit, (4) assist smokers in Funding: This work was supported by the Louisiana Cancer their quit attempt, and (5) arrange for follow-up contact. Furthermore, the CPG delineates standards Volume 13, Number 3, Fall 2013 Clinical Practice Guideline Effects on Tobacco Use for quality care, endorses the effectiveness of evi- nonpediatric primary care clinics. For each clinic, the dence-based treatments for tobacco use, and pro- survey was conducted during approximately 70 vides strategies for integrating screening and operating days during the quarter; for each stratum, treatment into routine patterns of care. Nearly 70% 2 of these operating days (a total of 44 3 2 ¼ 88) were of smokers visit a physician at least once a year, selected as the first-stage cluster sample. The second providing an opportunity for intervention.7 However, stage in 2004 involved choosing specific participants CPG implementation in primary care settings is less within each clinic-day combination. After further stratifying by age and gender, subjects were selected Patients' perceptions of their care have become randomly from appointments scheduled for the clinic increasingly important to health systems as many on the selected days.
seek to improve the quality and satisfaction with In 2010, the first-stage cluster sampling plan treatments and to provide patient-centered care.9,10 included 7 public hospitals in the system and 29 When tobacco users receive treatment according to nonpediatric clinics. For each clinic, a survey time was the CPG, they report higher satisfaction with overall assigned over a 2-week period. Each day, the healthcare received relative to untreated tobacco surveyors were required to visit 1 clinic for about 2 users.7 Provider treatment of tobacco use can be hours, either in the morning or the afternoon, thus measured by patient surveys (eg, Consumer Assess- designating a total of 10 slots for the 2-week period ment of Healthcare Providers and Systems, National (10 weekdays). The second stage in 2010 included Health Interview Survey), provider surveys, medical participants within each clinic-day combination. In this record reviews, and direct observation. However, survey, all subjects presenting to the clinic during the limitations exist for each of these and results vary.
assigned time slot were included. Because clinic While direct observation is the standard for assessing patient loads varied, the samples collected for each provider treatment, healthcare systems can benefit stratum were determined in proportion to the relative from precise, cost-effective, and practical approaches patient volume of each clinic.
to obtaining patient perceptions of provider interven-tion.11,12 Patient surveys are more accurate than chart Survey Instrument audits for assessing chronic disease advice, informa- Both surveys contained items found in other tion dissemination, and, in some instances, general national surveys (eg, National Health Interview Sur- health promotion.13 vey, Adult Tobacco Survey, Behavioral Risk Factor In 2002, to accompany an increase in the excise tax Surveillance System). The 2004 survey consisted of 8 on cigarettes, the Louisiana State University School of sections: Health Status, Health Care Access, Demo- Public Health (LSUSPH), in partnership with Louisi- graphics, Tobacco Use, Quit Attempts and Methods ana's safety-net healthcare system, created the To- to Quit, Stages of Change for Quitting, Physician and bacco Control Initiative (TCI). The TCI, described in Health Professional Behavior, and Other Tobacco detail elsewhere,14 employed a systems approach to Use. The 2010 survey consisted of 3 sections: facilitate implementation of the CPG in the LSU Tobacco Use, Quit Attempts and Methods to Quit, network of public hospitals. This report presents and Physician and Health Professional Behavior.
results from an assessment of patient tobacco use,quit attempts, and perceptions of provider treatment Survey Administration before (2004) and after (2010) the CPG implementation In 2004, surveys were administered by interview- in Louisiana's safety-net healthcare system.
ers and conducted in a private area in the clinic priorto the patients' interaction with the healthcare provider. After agreeing to take the survey, patients completed consent procedures and were informed In May 2004, patients ‡18 years old and using they would be compensated $10 for their time. The LSU as their principal source of primary care were response rate was 95%. Participants' responses were evaluated. Eligible participants met the condition of 1 recorded on a hard copy of the survey instrument.
or more visits to an LSU primary care clinic in the prior Payment was mailed after the interview.
year. A follow-up survey was conducted in January In 2010, considerations of cost and sustainability 2010. Participants were eligible in 2010 if they had resulted in changes to the survey methodology. Self- had 1 or more visits to an LSU primary care clinic administered surveys were distributed to all patients during survey administration.
presenting for a clinic visit with the request to A stratified, 2-stage, cluster sampling plan was complete them prior to their clinic visit. A TCI tobacco used in 2004 and 2010. In 2004, the first stage cessation coordinator provided clinic intake clerks included 10 public hospitals in the system and 44 with surveys, clipboards, and pencils that were given The Ochsner Journal to all patients at appointment check-in. This approach Changes in Patient Perceptions of Physician yielded a 99% response rate. Because survey and Health Professional Behaviors participation was both voluntary and anonymous, To determine if, in their interactions with smokers, and the survey was made available to all patients, it healthcare providers were following the CPG related was not necessary for patients to complete an to smoking cessation, smokers were questioned informed consent or patient privacy form. Participants about interactions with healthcare providers. Specif- did not receive compensation. The study was ically, smokers were asked about their tobacco use approved by the Institutional Review Board of the and whether the healthcare provider gave advice to LSU Health Sciences Center and by the Research quit smoking. Table 3 shows the patient-reported Review Committee of each facility.
healthcare provider behaviors regarding the CPG 5Aprotocol: ask, advise, assess, assist, and arrange. In 2004 and 2010, 86%-90% of patients reported that Descriptive statistics of the demographic charac- their healthcare provider had asked and advised them teristics of respondents were derived. For the purpose to quit smoking in the past 12 months. In 2010, of comparing 2004 and 2010 patients, the results however, healthcare providers did a better job in were standardized by the gender and age population assessing, assisting, and arranging. Table 3 shows distribution in 2010. All analyses were weighted to that 72% of patients had been assessed during the account for the complex sampling design. Chi-square past 12 months in 2010, but only 39% of patients were analyses were conducted to explore 2004 and 2010 assessed during the previous 12 months in 2004 differences among patients who were smokers.
(P<0.001). Similarly, 76% of patients had been Weighting of analytical procedures was accomplished assisted in the past 12 months in 2010, but only with SAS 9.1 (SAS Institute, Cary, NC). To allow valid 24% of patients had been assisted in the previous 12 comparison of groups, direct standardization (or months in 2004 (P<0.001). In addition, 31% of adjustment) of rates was used to minimize the patients had cessation services arranged in 2010, influence of confounding factors.
but only 8% of patients had services arranged in 2004(P<0.001).
RESULTSChanges in Demographic Status Changes in Patient-Reported Quit Attempts Included in the results were 571 patients in 2004 and 889 patients in 2010, representing the 7 hospitals Table 4 shows the quit-smoking behaviors in the Louisiana public hospital system that partici- reported by patients who smoked. Although the pated in both administrations of the survey. Table 1 proportion of smokers who stopped smoking for 1 shows the demographics for the samples. About two- day or longer was higher in 2010 (60%) vs 2004 thirds of the patients were ‡45 years old. The sample (49%), the difference was not statistically significant was predominantly female (82% in 2004 vs 71% in (P¼0.120). In 2010, a significantly higher proportion 2010). In 2004, most of the patients were African- of smokers reported being aware of assistance American (60%). In 2010, however, more than half the (70%) such as telephone quit lines or cessation patients were white (54%). Most patients were lower services at local LSU hospitals; however, only 19% of income, with 58% of the participants reporting free smokers were aware of such assistance in 2004 care (indigent) status in 2004 and 52% in 2010.
(P<0.001). Nearly the same percentage of those whosmoked cigarettes regularly and had stopped smok- Changes in Tobacco Use ing for 1 day or longer to quit smoking in the past 12 To compare patients in 2004 and 2010, the results months (75% in 2004 and 76% in 2010, P¼0.920) were standardized by gender and age distribution reported that they tried to quit smoking on their own using the 2010 population distribution. Chi-square (cold turkey). A significant difference was found in analyses were conducted to explore 2004 and 2010 the use of an aid to quit smoking. More smokers in differences among patients who were smokers. Table 2004 than in 2010 stated they used a stop-smoking 2 shows the tobacco use status in 2004 and 2010. In product such as a nicotine patch or bupropion general, the proportion of ever smokers was similar hydrochloride (Zyban) (23% in 2004 vs 5% in 2010, (54% vs 49%; P¼0.083). Between 2004 and 2010, no significant differences were found for the period oftime since ever smokers had last smoked cigarettes (P¼0.328). However, the percentage of heavy smok- The survey findings suggest that integrating the ers (those who smoke more than 11 cigarettes per USPHS CPG in a large public hospital system impacts day) was higher in 2004 than in 2010 (P<0.001).
patient tobacco use, quit attempts and methods for Volume 13, Number 3, Fall 2013 Clinical Practice Guideline Effects on Tobacco Use Table 1. Demographic Status May-Aug 2004 (n¼571) Jan-Feb 2010 (n¼889) Commercial insurance Free care/indigent Table 2. Tobacco Use in Patients Who Have Smoked at Least 100 Cigarettes in Their Lifetimes May-Aug 2004 (n¼529) Jan-Feb 2010 (n¼823) Have you smoked at least 100 cigarettes in your entire lifetime?a Do you now smoke cigarettes every day, some days, or not at all?a On average, about how many cigarettes a day do you smoke?a 1 – 10 cigarettes 11 – 20 cigarettes 21 – 35 cigarettes 40 or more cigarettes About how long has it been since you last smoked cigarettes regularly?a 1 to 3 months ago 3 to 6 months ago 6 to 12 months ago 5 or more years ago The Ochsner Journal Table 3. Physician and Health Professional Behaviors Asked - In the past 12 months, did any health care provider at this LSU Hospital ask if you smoke?Yes Advised - In the past 12 months, did any health care provider advise you to quit smoking?aYes Assessed - During the past 12 months, did any health care provider ask you if you were willing to make a quit attempt?aYes Assisted - In the past 12 months, when a health care provider advised you to quit smoking, did they do any of the following(prescribe or recommend medication, suggest setting quit date,recommend or refer to counseling, or give self-help material)?bYes Arranged - In the past 12 months, when a health care provider advised you to quit smoking, did they do any of the following(call and ask you about your quit attempt within one week orone month)?bYes aSmoked cigarettes regularly in the past 12 months.
bSmoked cigarettes regularly in the past 12 months and in the past 12 months healthcare provider advised patient to quit smoking.
Note: Weighted percentages reported for all questions of the 5A protocol.
quitting, and perceptions of provider treatment be- prevention programs and media campaigns focused havior. In 2010, fewer respondents reported ever on averting smoking initiation, the decrease in those smoking and heavy smoking. While the decrease smoking 11 or more cigarettes per day may result among ever smokers may be attributed to statewide from successful quit attempts either on their own or Table 4. Quit Attempts and Methods In the past 12 months, have you stopped smoking for one day or longer because you were trying to quit smoking?aYes Are you aware of assistance that might be available to help you quit smoking at this LSU Hospital such as telephonequit lines or local health clinic services?aYes The last time you tried to quit smoking did you quit cold turkey (on your own)?bYes The last time you tried to quit smoking, did you use a patch or Zyban to help you quit?bYes aSmoked cigarettes regularly in the past 12 months.
bSmoked cigarettes regularly and had stopped smoking for 1 day or longer to quit smoking in the past 12 months.
Note: Weighted percentages reported for all questions.
Volume 13, Number 3, Fall 2013 Clinical Practice Guideline Effects on Tobacco Use from utilizing cessation services in the LSU Health Respondents reported an increase in quit at- System. Since 2004, TCI has made free group tempts, and significantly more reported awareness behavioral counseling, self-help material, access to of assistance to help them quit. These increases low-cost pharmacotherapy, and, more recently, ac- suggest that TCI's efforts to ensure that all providers cess to free quit-line telephone counseling available were trained to identify and discuss best-practice to aid patient quit attempts. Compared to 2004, more treatment options with their patients were effective. In respondents in 2010 reported smoking 10 ciga- addition, TCI employed dedicated tobacco specialists rettes per day, daily smoking, and having smoked in to coordinate cessation services and to support the previous month. This trend suggests an emer- clinicians at each facility. The present results regard- gence of differing levels of smokers and their ing quit attempts were less favorable than results cessation pathways: smokers who are able to quit reported in primary care settings19 but higher than instudies among the uninsured.8 and maintain abstinence, smokers who quit and Between 2004 and 2010, no change was seen in relapse, and recalcitrant smokers.15 Relapsing and respondents who reported making a quit attempt on recalcitrant smokers are likely recycled in the health their own (cold turkey), and fewer respondents system16 and may need tailored services to improve reported making a quit attempt by using a nicotine quit attempts and abstinence rates.17 However, the patch or Zyban. This finding suggests efforts to smoking rate of survey participants in both 2004 and increase quit attempts using evidence-based strate- 2010 was higher than the rates reported for patients in gies were not equally effective. However, the de- other primary care settings18,19 and for patients who crease in use of a patch or Zyban may also be explained by increased access to and availability of Patient respondents reported an increase in all of varenicline (Chantix) starting in 2006,24 an option that the provider treatment measures, except advice to was not on the 2004 survey.
quit, which remained unchanged. There was a slight Study limitations should be noted. One limitation increase in provider screening for tobacco use and is that patient responses were based on their previous significant increases in providers who assessed clinic visit (ie, surveys were conducted before their patient willingness to quit, assisted patients with their current clinic visit). This delayed measurement and quit attempts, and arranged follow-up for patients reliance on recall may overestimate performance.12 A after the clinic visit.
second limitation is that the results were based on a These increases may indicate that TCI's effort to self-report method. Further, several commonly used galvanize the clinical and patient-level cessation methods to assess provider cessation counseling interventions by the LSU Health System were effec- have limitations. Patient surveys may under-23 or tive, and this systems-based approach may serve as a overestimate,25,26 provider surveys may overesti- model for future statewide intervention efforts to mate,23,27 paper medical charts may underesti- decrease patient tobacco use through the systematic mate,25,26,28,29 and electronic medical records may implementation and evaluation of the USPHS CPG for underestimate all items on the 5A protocol, except for treating tobacco use by healthcare providers. Identi- asking about tobacco use.11 Direct observation, the fication and documentation of tobacco users were ideal method, is burdensome and costly.29 Health- obtained from nursing assessment forms, followed by care systems can benefit from precise, cost-effective, TCI referral forms, and finally from electronic medical and practical approaches to assessing treatment fortobacco use, and this type of onsite survey distribu- records with prompts and reminders for intervention.
tion proved to be an effective strategy for data Systemwide adoption of a tobacco treatment policy, collection in Louisiana's public hospital system.
training to improve provider intervention skills, andprovider feedback on clinical performance via an electronic dashboard occurred throughout the sys- This study—which examined patient tobacco use, tem. These multilevel cessation interventions, includ- quit attempts and methods, and perceptions of ing counseling and medication, have been successful physician behavior to treat tobacco use among in improving adherence to the USPHS CPG for primary care patients in Louisiana's safety-net health- treatment of tobacco use in primary care settings.21 care system—found positive changes between 2004 Although few studies have reported patient percep- and 2010. During this time frame, practice guidelines tions of provider adherence to the 5A approach (ask, for the treatment of tobacco use and dependence advise, assess, assist, arrange) in primary care were implemented. Obviously, these results do not settings, overall our results were more favorable than indicate cause and effect because this study was a those found by others in similar settings11,18,22,23 and nonrandomized and noncontrolled observation. Other in studies of the uninsured.8 extraneous factors may have promoted improve- The Ochsner Journal ments in many of the items measured; however, some Bleich SN, Ozaltin E, Murray CK. How does satisfaction with the differences are quite large and statistically significant.
health-care system relate to patient experience? Bull World Therefore, these results overall indicate a positive Health Organ. 2009 Apr;87(4):271-278.
trend in patient behaviors and perceptions of provider 10. Sofaer S, Firminger K. Patient perceptions of the quality of health care after implementation of the 5A clinical protocol.
Annu Rev Public Health. 2005;26:513-559.
11. Conroy MB, Majchrzak NE, Silverman CB, et al. Measuring These observations have implications for eliminating provider adherence to tobacco treatment guidelines: a tobacco use at the population level, especially among comparison of electronic medical record review, patient survey, ethnic/racial minorities, those of low socioeconomic and provider survey. Nicotine Tob Res. 2005 Apr;7(Suppl 1):S35- status, and the under- and uninsured. Future studies should examine the effects of implementation exper- 12. Houston TK, Richman JS, Coley HL, et al; DPBRN imentally in a randomized-controlled trial and com- Collaborative Group. Does delayed measurement affect patient pare patient responses to clinician (electronic) reports of provider performance? Implications for performance documentation. Furthermore, tailored interventions measurement of medical assistance with tobacco cessation: a that target relapsed and recalcitrant smokers and Dental PBRN study. BMC Health Serv Res. 2008 May 8;8: the use of evidence-based strategies during quit attempts are warranted. Decreasing tobacco use is 13. Green ME, Hogg W, Savage C, et al. Assessing methods for measurement of clinical outcomes and quality of care in primary a top objective of Healthy People 2020.30 Improving care practices. BMC Health Serv Res. 2012 Jul 23;12:214.
the quality of treatment through a systems-based 14. Moody-Thomas S, Celestin M Jr., Horswell R. Use of systems approach may impact the disproportionate use of change and health information technology to integrate tobacco in especially disparate populations.
comprehensive tobacco cessation services in a statewidesystem for delivery of healthcare. Open J Prev Med. 2013; U.S. Department of Health and Human Services. How Tobacco 15. Wynd CA. Smoking patterns, beliefs, and the practice of healthy Smoke Causes Disease: The Biology and Behavioral Basis for behaviors in abstinent, relapsed, and recalcitrant smokers. J Vasc Smoking-Attributable Disease: A Report of the Surgeon General.
Nurs. 2007 Jun;25(2):32-38.
Atlanta, GA: U.S. Department of Health and Human Services, 16. Partin MR, An LC, Nelson DB, et al. Randomized trial of an Centers for Disease Control and Prevention, National Center for intervention to facilitate recycling for relapsed smokers. Am J Chronic Disease Prevention and Health Promotion, Office on Prev Med. 2006 Oct;31(4):293-299. Epub 2006 Aug 22.
Smoking and Health; 2010.
17. Sherman SE. A framework for tobacco control: lessons learnt Garrett BE, Dube SR, Trosclair A, Caraballo RS, Pechacek TF; from Veterans Health Administration. BMJ. 2008 May 3; Centers for Disease Control and Prevention (CDC). Cigarette smoking - United States, 1965-2008. MMWR Surveill Summ.
18. Ferrante JM, Ohman-Strickland P, Hahn KA, et al. Self-report 2011 Jan 14;60(Suppl):109-113.
versus medical records for assessing cancer-preventive services Centers for Disease Control and Prevention (CDC). Vital signs: delivery. Cancer Epidemiol Biomarkers Prev. 2008 Nov;17(11): current cigarette smoking among adults aged ‡18 years with mental illness - United States, 2009-2011. MMWR Morb Mortal 19. Ralston S, Kellett N, Williams RL, Schmitt C, North CQ. Practice- Wkly Rep. 2013 Feb 8;62(5):81-87.
based assessment of tobacco usage in southwestern primary Centers for Disease Control and Prevention. Tobacco Control care patients: a Research Involving Outpatient Settings Network State Highlights 2012. Atlanta: U.S. Department of Health and (RIOS Net) study. J Am Board Fam Med. 2007 Mar-Apr;20(2): Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health 20. Centers for Disease Control and Prevention. Quitting smoking Promotion, Office on Smoking and Health; 2013.
among adults—United States, 2001–2010. MMWR. 2011; National Center for Health Statistics. Health, United States, 2009: With Special Feature on Medical Technology. Hyattsville, MD: 21. Papadakis S, McDonald P, Mullen KA, Reid R, Skulsky K, Pipe A.
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Strategies to increase the delivery of smoking cessation Louisiana Department of Health and Hospitals. 2010 Behavioral treatments in primary care settings: a systematic review and Risk Factor Surveillance System Report. Baton Rouge, LA: meta-analysis. Prev Med. 2010 Sep-Oct;51(3-4):199-213. Epub Louisiana Department of Health and Hospitals; 2012.
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Fiore MC, Jaen CR, Baker TB, et al. Treating Tobacco Use and 22. Ahluwalia JS, Gibson CA, Kenney RE, Wallace DD, Resnicow K.
Dependence: 2008 Update. Clinical Practice Guideline. Rockville, Smoking status as a vital sign. J Gen Intern Med. 1999 Jul;14(7): MD: U.S. Department of Health and Human Services; Public Health Service; 2008.
23. Thorndike AN, Rigotti NA, Stafford RS, Singer DE. National Jamal A, Dube SR, Malarcher AM, Shaw L, Engstrom MC; patterns in the treatment of smokers by physicians. JAMA. 1998 Centers for Disease Control and Prevention (CDC). Tobacco use screening and counseling during physician office visits among 24. USFDA. FDA Approves Novel Medication for Smoking Cessation: adults—National Ambulatory Medical Care Survey and National US Food and Drug Administration, May 11, 2006. http://www.fda.
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Volume 13, Number 3, Fall 2013 Clinical Practice Guideline Effects on Tobacco Use 25. Pbert L, Adams A, Quirk M, Hebert JR, Ockene JK, Luippold RS.
28. Nicholson JM, Hennrikus DJ, Lando HA, McCarty MC, Vessey J.
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26. Wilson A, McDonald P. Comparison of patient questionnaire, 29. Stange KC, Zyzanski SJ, Smith TF, et al. How valid are medical medical record, and audio tape in assessment of health records and patient questionnaires for physician profiling and promotion in general practice consultations. BMJ. 1994 Dec 3; health services research? A comparison with direct observation of patients visits. Med Care. 1998 Jun;36(6):851-867.
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This article meets the Accreditation Council for Graduate Medical Education and the American Board ofMedical Specialties Maintenance of Certification competencies for Patient Care, Systems-Based Practice,and Practice-Based Learning and Improvement.
The Ochsner Journal

Source: http://ochsnerjournal.org/doi/pdf/10.1043/1524-5012-13.3.367


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