Putting Public Health Into Practice
2012; Elsevier BV; Volume: 42; Issue: 6 Linguagem: Inglês
10.1016/j.amepre.2012.03.020
ISSN1873-2607
AutoresHilary Parton, Sharon E. Perlman, Ram Koppaka, Carolyn M. Greene,
Tópico(s)Healthcare Policy and Management
ResumoThe New York City (NYC) Department of Health and Mental Hygiene (Health Department) surveyed practicing New York City physicians to quantify Health Department resource use. Although the Health Department successfully reaches most physicians, and information is valued in practice, knowledge of several key resources was low. Findings suggested three recommendations for all local health departments seeking to enhance engagement with practicing physicians: (1) capitalize on physician interest, (2) engage physicians early and often, and (3) make interaction with the health department easy. Also, older physicians may require targeted outreach. Collaborative relationships can help health departments and physicians advance shared goals of health promotion and protection.1IOMThe Future of the Public's Health in the 21st Century. National Academies Press, Washington, DC2002Google Scholar, 2Dworkin M.S. Adults are whooping, but are internists listening?.Ann Intern Med. 2005; 142: 832-835Crossref PubMed Scopus (30) Google Scholar, 3Brill J. Swain G.R. Physicians should collaborate with local health department.Am Fam Physician. 2009; 79: 180PubMed Google Scholar, 4Campos-Outcalt D. Public health and family medicine: an opportunity.J Am Board Fam Pract. 2004; 17: 207-211Crossref PubMed Scopus (12) Google Scholar, 5Farley T.A. Dalal M.A. Mostashari F. Frieden T.R. Deaths preventable in the U.S. by improvements in use of clinical preventive services.Am J Prev Med. 2010; 38: 600-609Abstract Full Text Full Text PDF PubMed Scopus (192) Google Scholar The NYC Health Department regularly interacts with physicians through communications, publications, and clinical guidance. Certain Health Department programs target specific NYC physician populations and have evaluated these efforts.6Larson K. Levy J. Rome M.G. Matte T.D. Silver L.D. Frieden T.R. Public health detailing: a strategy to improve the delivery of clinical preventive services in New York City.Public Health Rep. 2006; 121: 228-234PubMed Google Scholar, 7Udeagu C.C. Bocour A. Gale I. Begier E.M. Provider and client acceptance of a health department enhanced approach to improve HIV partner notification in New York City.Sex Transm Dis. 2010; 37: 266-271PubMed Google Scholar, 8Silin M. Laraque F. Munsiff S.S. Crossa A. Harris T.G. The impact of monitoring tuberculosis reporting delays in New York City.J Public Health Manag Pract. 2010; 16: E09-E17Google Scholar However, the Health Department has not systematically assessed the effectiveness of engagement with NYC physicians overall. The current survey was conducted to quantify physician knowledge and use of Health Department resources. From November 2009 through February 2010, a survey was conducted of physicians selected from an American Medical Association Physician Masterfile list.9American Medical AssociationPhysician data resources – AMA Physician Masterfile.www.ama-assn.org/ama/pub/about-ama/physician-data-resources/physician-masterfile.pageGoogle Scholar The Health Department interacts mostly with primary care physicians, approximately 30% of the NYC physician population. To ensure an adequate sample of this population, a random selection was made of 840 primary care physicians and 360 non–primary care physicians. The questionnaire took approximately 15 minutes to complete, and an electronic version was created with Survey Monkey.10Survey Monkeywww.surveymonkey.comGoogle Scholar Paper copies of the survey were mailed with a cover letter from the Commissioner of Health; a preaddressed, stamped envelope; a card for one subway or bus ride; and two optional forms: one for entrance into a lottery for one of five 1-year subscriptions to MD Consult,11MD Consultwww.mdconsult.comGoogle Scholar and one for future focus group participation. Physicians could participate by paper or through a provided web link. (Detailed methods and the questionnaire are included in Appendix A, Appendix B, Appendix C). Respondents were eligible if they reported seeing patients at least 10 hours a week and practiced primarily in NYC. Univariate analyses described respondent demographics and practice characteristics compared with all NYC physicians.12Armstrong D.P. Forte G.J. Annual New York Physician Workforce Profile.2009 Edition. Center for Health Workforce Studies, School of Public Health, SUNY Albany, Rensselaer, NY2009Google Scholar Bivariate analyses examined differences among respondents by demographic and practice characteristics. In all, 626 unique surveys and 105 focus group participation forms were received. Eighty-two invalid records were removed (not practicing or not in NYC) from the original sample for a response rate of 56%. There were 128 ineligible respondents, leaving 498 eligible records in the final data set. (A flowchart detailing the survey sample and response is provided in Appendix D.) Survey respondents were more likely to be women and to work in community health centers but were comparable to all NYC physicians in terms of age and location of medical school (Table 1). Nearly half (49%) provided direct patient care at least 40 hours per week; 38% reported that most patients in their practice were uninsured or covered only through Medicaid, and 53% used electronic health records.Table 1Descriptive characteristics of physician survey sample, n (%)CharacteristicNYC Health Department surveyNYC physician profileaInformation on all NYC physicians was obtained from the Center for Health Workforce Studies 2009 Annual New York Physician Workforce Profile.12p-valueMode of completed surveys Mail383 (77)—NA Internet57 (11)— Telephone58 (12)—Primary practice focusbPrimary care physicians included those who indicated a specialty in general pediatrics, general internal medicine, obstetrics/gynecology, family medicine, and general practice in the American Medical Association's Physician Masterfile list used to select our sample. This group was intentionally oversampled. Primary care300 (61)9,435 (29)NA Specialty192 (39)22,930 (71)Age, years <45 190 (38)10,357 (32)0.63 45–64245 (49)16,830 (52) ≥6563 (13)5,178 (16)Gender Female232 (47)11,004 (34)<0.01 Male266 (53)21,361 (66)Location of medical school New York State194 (39)11,328 (35)0.15 Other U.S.112 (22)8,091 (25) Foreign192 (38)12,946 (40)Practice type Solo139 (30)10,033 (31)0.01 Partnership or group97 (21)8,415 (26) Community health center or hospital227 (49)13,917 (43)Time spent providing direct clinical care, hours/weekcRespondents providing less than 10 h/wk of direct patient care were excluded. 10–1959 (12)—NA 20–2979 (16)— 30–39114 (23)— ≥40246 (49)—Proportion of patients in practice uninsured or covered only through Medicaid All20 (4)—NA ≥half, but less than all165 (34)— <half, but more than none172 (35)— None81 (16)— Don't know54 (11)—Uses electronic health records in practice Yes259 (53)—NA No233 (47)—Note: Table shows overall characteristics and comparisons to New York State Physician Profile of NYC Physicians, November 2009 to February 2010. Survey totals may not add to 498 because of missing values (n=6 for primary practice focus; n=35 for practice type; n=6 for proportion of patients in practice uninsured or covered only through Medicaid; and n=6 for use of electronic medical records). Percentages are calculated based on nonmissing data.Health Department, Department of Health and Mental Hygiene; NA, not applicable; NYC, New York Citya Information on all NYC physicians was obtained from the Center for Health Workforce Studies 2009 Annual New York Physician Workforce Profile.12Armstrong D.P. Forte G.J. Annual New York Physician Workforce Profile.2009 Edition. Center for Health Workforce Studies, School of Public Health, SUNY Albany, Rensselaer, NY2009Google Scholarb Primary care physicians included those who indicated a specialty in general pediatrics, general internal medicine, obstetrics/gynecology, family medicine, and general practice in the American Medical Association's Physician Masterfile list used to select our sample. This group was intentionally oversampled.c Respondents providing less than 10 h/wk of direct patient care were excluded. Open table in a new tab Note: Table shows overall characteristics and comparisons to New York State Physician Profile of NYC Physicians, November 2009 to February 2010. Survey totals may not add to 498 because of missing values (n=6 for primary practice focus; n=35 for practice type; n=6 for proportion of patients in practice uninsured or covered only through Medicaid; and n=6 for use of electronic medical records). Percentages are calculated based on nonmissing data. Health Department, Department of Health and Mental Hygiene; NA, not applicable; NYC, New York City Most respondents (82%) reported receiving Health Department communication, but only 37% had received information specifically through the Health Alert Network (HAN)13New York City Department of Health and Mental HygieneHealth care providers: programs and services.home2.nyc.gov/html/doh/html/hcp/hcp.shtmlGoogle Scholar; primary care physicians were more likely than specialists to have received any communication and the HAN specifically (Table 2). Less than one third (31%) of respondents were aware of the universal reporting form;14New York City Department of Health and Mental HygieneHealth care providers: the Universal Reporting Form (URF).www.nyc.gov/html/doh/html/hcp/hcp-urf.shtmlGoogle Scholar primary care physicians had higher awareness than specialists. Few (14%) were aware of the Health Department on-call physicians after hours.13New York City Department of Health and Mental HygieneHealth care providers: programs and services.home2.nyc.gov/html/doh/html/hcp/hcp.shtmlGoogle Scholar Overall, 47% preferred to receive Health Department publications by e-mail, and this preference was inversely associated with age. Younger respondents, particularly those aged <45 years, were more likely to prefer to receive e-mail publications.Table 2Interactions between physician survey respondents and the NYC Health Department, November 2009 to February 2010, n (%) unless otherwise notedRespondent characteristicTotal, nNYC Health Department outreach to physiciansPhysician communication to the NYC Health DepartmentEver received communication from NYC Health DepartmentaEver received a NYC Health Department publication, including the Health Alert NetworkpEver received information through Health Alert NetworkbThe Health Alert Network is an electronic notification system that provides information on urgent and emergency public health situations.13 communicationspPrefer to receive NYC Health Department publications by e-mailpAware of the universal reporting formcThe universal reporting form is used to report notifiable diseases or conditions to the NYC Health Department.14 This form may be submitted through mail or fax, and can be submitted electronically through the Health Department's online application, Reporting Central (available since the summer of 2009).pContacted NYC Health Department for information or advicedVisited NYC Health Department website or contacted NYC Health Department for clinical guidance in the past yearpOverall498403 (82)—178 (37)—180 (47)—149 (31)—303 (61)—Primary practice focus Primary care300268 (90)<0.01123 (42)<0.01114 (44)0.23112 (39)<0.01215 (72)<0.01 Specialist192134 (70)55 (29)66 (53)37 (20)87 (45)Age, years <45190144 (77)0.0553 (29)0.0679 (57)<0.0149 (27)0.01120 (63)0.14 45–64245207 (86)102 (43)90 (45)88 (38)152 (63) <656352 (84)23 (37)11 (22)12 (20)31 (50)Practice type Solo139115 (84)0.6346 (34)0.6438 (34)<0.0148 (36)0.1885 (62)0.02 Group9779 (84)38 (41)36 (49)30 (34)68 (72) Community health center or hospital227182 (81)78 (35)93 (53)60 (27)126 (56)Health Department, Department of Health and Mental Hygiene; NYC, New York Citya Ever received a NYC Health Department publication, including the Health Alert Networkb The Health Alert Network is an electronic notification system that provides information on urgent and emergency public health situations.13New York City Department of Health and Mental HygieneHealth care providers: programs and services.home2.nyc.gov/html/doh/html/hcp/hcp.shtmlGoogle Scholarc The universal reporting form is used to report notifiable diseases or conditions to the NYC Health Department.14New York City Department of Health and Mental HygieneHealth care providers: the Universal Reporting Form (URF).www.nyc.gov/html/doh/html/hcp/hcp-urf.shtmlGoogle Scholar This form may be submitted through mail or fax, and can be submitted electronically through the Health Department's online application, Reporting Central (available since the summer of 2009).d Visited NYC Health Department website or contacted NYC Health Department for clinical guidance in the past year Open table in a new tab Health Department, Department of Health and Mental Hygiene; NYC, New York City Most (61%) respondents contacted the Health Department for information in the past year, particularly those in primary care and in solo or group practices. Most respondents who used Health Department resources agreed that the information was useful in their practice: 87% of those who had contacted the Health Department for clinical guidance in the past year, 82% who had visited the website in the past year, 75% who had ever received the clinical guidelines bulletin for primary care physicians,15New York City Department of Health and Mental HygieneCity Health Information.www.nyc.gov/html/doh/html/chi/chi.shtmlGoogle Scholar and 70% who ever had received the HAN. This survey confirmed that the Health Department successfully reaches many physicians, particularly primary care providers. Findings also provided surprising insights into NYC physicians. First, physicians were receptive to engagement with the Health Department, as indicated by the high response to the survey and the reported value of Health Department resources in practice. Second, many physicians remain unaware of important Health Department resources, particularly the universal reporting form. Third, older physicians preferred to receive printed publications. The current study had several limitations. Generalizability may be limited because of deliberate oversampling of primary care physicians. In addition, the sample size was not large enough to assess differences by practice location. Also, this survey relies on self-reported data so it may over- or under-estimate physician awareness. Despite these limitations, the current findings prompt the following recommendations. Many physicians want to be engaged in public health initiatives. Health departments should direct topical and timely resources to physicians, taking their media preferences into account, and increase awareness of existing resources. Health departments should enhance outreach to physicians, providing clinician-friendly materials that emphasize the application of public health in clinical practice. In addition, collaborations with clinical residency programs can make regular communication habit rather than requirement among future community providers. Such collaborations can also enhance public health curricula during training and promote mutual understanding of and respect for each partner's roles and responsibilities. Establishing and maintaining physician contact registries, including e-mail addresses, can also facilitate more frequent and rapid communication at minimal cost. Health departments should use new technology to facilitate communication with physicians. As more physicians adopt technologies such as electronic health records and social media, health departments should use these tools to engage physicians and promote public health. Outreach strategies should account for physician preferences, such as providing print materials to older providers. Collaborative relationships between health departments and physicians are mutually beneficial and enhance each group's ability to effectively promote health. Physician surveys enable assessment of physicians' interactions with their local health department and represent an important step in increasing physician engagement in public health. Publication of this article was supported by the U.S. DHHS Health Resources and Services Administration (HRSA) and the NIH National Institute on Minority Health and Health Disparities. The authors thank Lorna Thorpe of the City University of New York, Joseph Egger of SciMetrika, and Katherine Bartley of the NYC Health Department for their support on the initial design of this project. The authors thank Carlos Espada and the NYC Health Department Call Center staff for their assistance with data collection. The authors thank the following staff from the NYC Health Department Bureau of Public Health Training, who were instrumental in the survey distribution and processing: Janice Blake, Kimsue Bryan, Tsering Choden, Peter Ephross, Tanya Fareira, Berton Freedman, Calaine Hemans-Henry, Raymond Jimenez, Bridgette Parrish, Jennifer Rose, Deloris Sands, Rhoda Schlamm, Nilsa Torres, and Verliene Wade. Human participant protection: The NYC Health Department Office of the General Counsel deemed this study a nonresearch public health activity not subject to IRB review. No financial disclosures were reported by the authors of this paper. A survey was conducted of physicians selected from an American Medical Association Physician Masterfile list, limited to approximately 18,000 physicians with active New York State (NYS) licenses and primary office addresses in New York City (NYC). Primary care physicians (defined as general pediatrics, general internal medicine, obstetrics/gynecology, gynecology, family medicine and general practice) make up approximately 30% of the NYC physician population, but were 70% of the current sample. To detect a 15% difference in response between primary care and non–primary care physicians with 90% power, and assuming a 50% response rate, a sample size of 1200 physicians was needed. The total list of physicians was divided into primary care and non-primary care, and random selection was made of 840 primary care physicians and 360 non-primary care physicians. Reminders (postcards, a second packet of survey materials, and reminder e-mails to those with e-mail information available) were distributed to encourage response. Almost 2 months after the initial mailing, Health Department Call Center employees who had been trained to administer the survey contacted nonrespondents using available telephone information to (1) complete the survey by phone when they reached the physician, (2) schedule a future date to complete the survey with the physician by phone, (3) resend the survey materials to the physician or (4) if appropriate, update information for the physician (e.g., new address, relocation out of NYC, retirement). Additional detail can be found in Appendix C. Surveys completed by paper or by phone were manually entered into Survey Monkey (www.surveymonkey.com) by Health Department staff. Results were downloaded into Microsoft Excel (2003) and imported into SAS 9.2 for analysis. Even though the survey was conducted with a relatively small budget and no additional staff, the response rate was 56%, due in part to the use of the Health Department's Call Center. The Call Center outreach resulted in a large number of additional surveys completed by mail (n=29) and Internet (n=31) in addition to those completed by phone (n=74). Also, through the work of the Call Center, an additional 21 sample records were identified as invalid. However, even without the Call Center, a response rate of 44% was estimated. Surprisingly, only 11% of eligible surveys were completed online, due in part to the small number of available e-mail addresses. The majority of physicians were offered only the online survey option through a link provided in the mailed materials. Tabled 1TimingAudienceActionExtra materials included with surveyPossible outcomes-AllMailed paper copies of the survey •A cover letter from the Commissioner of Health•A $2 MetroCard incentive (good for one subway or bus ride)•One optional form for entrance into a lottery for one of five 1-year subscriptions to MD ConsultaMD Consult, www.mdconsult.com/•One optional form for participation in focus groups to provide additional qualitative feedback •Completing the paper copy and returning it in a preaddressed stamped envelope•Completing the survey online using a web link provided in both the cover letter and on the survey + 10 daysAllReminder postcard •None •Completing the paper copy and returning it in the preaddressed stamped envelope originally sent•Completing the survey online using a web link provided in the original materials and on the reminder postcard + 3 weeksNonrespondentsMailed paper copies of the survey •Reminder letter from the Deputy Commissioner for the Division of Epidemiology•One optional form for entrance into a lottery for one of five 1-year subscriptions to MD ConsultaMD Consult, www.mdconsult.com/•One optional form for participation in focus groups to provide additional qualitative feedback •Completing the paper copy and returning it in a preaddressed stamped envelope•Completing the survey online using a web link provided in both the cover letter and on the survey + 5 weeksNonrespondents with e-mail address information availableReminder e-mail •None •Completing a paper copy and returning it in the preaddressed stamped envelope•Completing the survey online using a web link provided in the e-mail + 1.5 monthsNonrespondents with telephone information availableNYC Health Department Call Center outreach •None • Call Center staff were instructed to pursue the following options, in order of preference:(1) complete the survey by phone when they reached the physician,(2) schedule a future date to complete the survey with the physician by phone,(3) resend the survey materials to the physician or(4) if appropriate, update information for the physician (e.g., new address, relocation out of NYC, retirement). NYC, New York Citya MD Consult, www.mdconsult.com/ Open table in a new tab NYC, New York City
Referência(s)