Abstract
Previous research on geographic variations in health care contains limited information regarding inner-city medical practice compared with suburban and rural settings. Our main objective was to compare patient characteristics and the process of providing medical care among family practices in inner-city, suburban, and rural locations. A cross-sectional multimethod study was conducted emphasizing direct observation of out patient visits by trained research nurses involving 4, 454 consecutive patients presenting for outpatient care to 138 family physicians during 2 days of observation at 84 community family practices in northeast Ohio. Time use during office visits was assessed with the Davis Observation Code; satisfaction was measured with the Medical Outcomes Study nine-item Visit Rating Scale; delivery of preventive services was as recommended by the US Preventive Services Task Force; and patient-reported domains of primary care were assessed with the Components of Primary Care Instrument. Results show that inner-city patients had more chronic medical problems, more emotional problems, more problems evaluated per visit, higher rates of health habit counseling, and longer and more frequent office visits. Rural patients were older, more likely to be established with the same physician, and had higher rates of satisfaction and patient-reported physician knowledge of the patient. Suburban patients were younger, had fewer chronic medical problems, and took fewer medications chronically. Inner-city family physicians in northeast Ohio appear to see a more challenging patient population than their rural and suburban counterparts and have more complex outpatient office visits. These findings have implications for health system organization along with the reimbursement and recruitment of physicians in medically underserved inner-city areas.
This is a preview of subscription content, log in via an institution to check access.
Similar content being viewed by others
References
Council on Graduate Medical Education. Third Report—Improving Access to Health Care Through Physician Workforce Reform: Direction for the 21st Century, Rockville, MD: US Dept of Health and Human Services, Public Health Service, Health Resources and Service Administration; 1992.
Norton CH, McManus MA. Background tables on demographic characteristics, health status, and health services utilization. Health Serv Res. 1989;23:725–756.
Baldwin L, Hart G, West PA, Norris TE, Gore E, Schneeweiss R. Two decades of experience in the University of Washington Family Medicine Residency Network: practice differences between graduates in rural and urban locations. J Rural Health. 1995;11: 60–72.
Lin GE, Rosenthal TC, Horwitz M. Physician location survey: self-reported and censusdefined rural/urban locations. Soc Sci Med. 1997;44:1761–1766.
Dwyer JW, Lee GR, Coward RT. The health status, health services utilization, and support networks of the rural elderly: a decade of review. J Rural Health. 1990;6:379–398.
Harris R, Leininger L. Preventive care in rural primary care practice. Cancer. 1993;72: 1113–1118.
US Congress, Office of Technology Assessment. Health Care in Rural America. Washington, DC: US Government Printing Office; September 1990. Publication OTA-H-434.
Centers for Disease Control and Prevention. State-to-state variation in screening mammograms for women 50 years of age and older: Behavioral Risk Factor Surveillance System, 1987. MMWR Morb Mortal Wkly Rep. 1989;38:157–160.
Baldwin L, Rosenblatt RA, Schneeweiss R, Lishner DM, Hart LG. Rural and urban physicians: does the content of their Medicare practices differ? J Rural Health. 1999; 15:240–251.
Becker P, Hartz A, Cutler J. Time trends in the association of rural or urban background with physical location. J Med Educ. 1979;54:544–550.
McConnel CE, Zetzman MR. Urban/rural differences in health service utilization by elderly persons in the United States. J Rural Health. 1993;9:270–280.
Himes CL, Rutrough TS. Differences in the use of health services by metropolitan and nonmetropolitan elderly. J Rural Health. 1994;10:80–88.
Schappert SM. Advance data from vital and health statistics. Advance Data. In National Ambulatory Medical Care Survey: 1994 Summary. Hyattsville, MD: National Center for Health Statistics; 1996;1–20.
Stange KC, Zyzanski SJ, Jaén CR, et al. Illuminating the “black box”: a description of 4,454 patient visits to 138 family physicians. J Fam Pract. 1998;46:377–389.
Donaldson MS, Yordy KD, Lohr KN, Vanselow NA. Primary Care: America’s Health in a New Era. Washington, DC: National Academy Press; 1996.
Stange KC, Zyzanski SJ, Smith TF, et al. How valid are medical records and patient questionnaires for physician profiling and health services research? A comparison with direct observation of patient visits. Med Care, 1998;36:851–867.
Kirschner CG, Burkett RC, Coy JA, et al. Physicians’ Current Procedural Terminology: CPT ’95. Chicago, IL: American Medical Association; 1994.
Ware J, Nelson E, Sherbourne C, Steward A. Preliminary tests of a six-item general health survey: a patient application. In: Ware J, ed. Measuring Functioning and Well-Being. Durham, NC: Duke University Press; 1992:291–307.
Schneeweiss R, Rosenblatt RA, Cherkin DC, Kirkwood CR, Hart G. Diagnosis clusters: a new tool for analyzing the content of ambulatory medical care. Med Care. 1983;21: 105–122.
Schneeweiss R, Cherkin DC, Hart LG, et al. Diagnosis clusters adapted for ICD-9-CM and ICHPPC-2. J Fam Pract. 1986;22:69–72.
US Preventive Services Task Force. Guide to Clinical Preventive Services. 2nd ed. Baltimore, MD: Williams and Wilkins; 1996.
Flocke SA, Stange KC, Zyzanski SJ. The association of attributes of primary care with preventive service delivery. Med Care. 1998;36:AS21-AS30.
Stange KC, Flocke SA, Goodwin MA, Kelly RB, Zyzanski SJ. Direct observation of rates of preventive service delivery in community family practice. Prev Med. 2000;31: 167–176.
Rubin H, Gandek B, Roger WH, Kosinski M, McHorney CA, Ware J. Patient’s rating of outpatient visits in different practice settings: results from the Medical Outcomes Study. JAMA. 1993;270:835–840.
Flocke SA. Measuring attributes of primary care: development of a new instrument. J Fam Pract. 1997;45:64–74.
American Academy of Family Physicians. 1996 Facts About Family Practice. Kansas City, MO: American Academy of Family Physicians; 1996.
Centers for Disease Control and Prevention. Increased cholesterol awareness in urban and rural areas: Missouri, 1988–1991. MMWR Morb Mortal Wkly Rep. 1992;41:323–325.
Cordes SM. The changing rural environment and the relationship between health services and rural development. Health Serv Res. 1989;23:757–784.
Chao J, Gillanders WG, Flocke SA, Goodwin MA, Kikano GE, Stange KC. Billing for physician services: a comparison of actual billing with CPT codes assigned by direct observation. J Fam Pract. 1998;47:28–32.
Kikano GE, Goodwin MA, Stange KC. Evaluation and management services. A comparison of medical record documentation with actual billing in community family practice. Arch Fam Med. 2000;9:68–71.
Author information
Authors and Affiliations
Rights and permissions
About this article
Cite this article
Blankfield, R.P., Goodwin, M., Jaén, C.R. et al. Addressing the unique challenges of inner-city practice: a direct observation study of inner-city, rural, and suburban family practices. J Urban Health 79, 173–185 (2002). https://doi.org/10.1093/jurban/79.2.173
Issue Date:
DOI: https://doi.org/10.1093/jurban/79.2.173