Purpose: Delivery of preventive services falls short of guideline recommendations. We evaluate the multilevel factors associated with missed opportunities to deliver evidence-based preventive services during periodic health examinations (PHE).
Method: Physician subjects (N=64) were general internal medicine and family physicians practicing in 2007-2009 with an integrated delivery system in southeast Michigan. Patient subjects (N=484) were insured, aged 50-80 years, and due for colorectal cancer screening. Office visit audio-recordings were used to ascertain physician recommendation for/delivery of 19 services recommended by the US Preventive Services Task Force and Advisory Committee on Immunization Practices. A patient survey and claims data were used to determine patient service eligibility/due status. Alternating logistic regression with individual service delivery as the outcome evaluated patient, physician, visit and contextual factors associated with missed opportunities. Models nested services within patients and patients within physicians as well as controlled for service type.
Result: Among N=2662 services for which patients were due, 46% were not delivered. Services with highest rates of missed opportunities included aspirin counseling (82%), vision screening (81%) and influenza vaccination (80%). Those with lowest rates included colorectal cancer (7%) hypertension (8%) and breast cancer (10%) screening. Regression results indicated the likelihood of a missed opportunity increased with patient age (OR=1.03; 95% CI= 1.01-1.05) and each additional concern the patient raised (1.24; 1.09-1.40), decreased with increasing patient body mass index (0.98; 0.97-1.00) and each additional minute after scheduled appointment time the physician first presented (0.99; 0.98-1.00), and was greater if the physician used the electronic medical record (EMR) in the exam room (1.40; 1.06-1.86), was of a different gender than the patient (1.37; 1.05-1.79), and had seen the patient in the past 12 months (1.40; 1.06-1.86).
Conclusion: Almost half of recommended preventive services are not delivered to patients during PHEs. A combination of patient, physician, visit and contextual factors are associated with missed opportunities. While physicians appear not to skip delivery of due services when running late, delivery can be compromised when patients raise competing demands, and when the EMR is used in the exam room. The public health and economic impact of missed opportunities to deliver preventive services is profound and warrants additional studies to understand the complex interplay of factors that support and compromise preventive service delivery.