A Controlled Evaluation of the Effectiveness of Comprehensive Pediatric Care in Influencing Patient Compliance

Abstract

ALVIN H.NOVACK (New Haven, Conn.): Dr. GORDIS, I want to indicate that it is important that we measure the differences between comprehensive and episodic care. I would, however, raise a question as to the definition of comprehensive care. I think you have measured the difference between comprehensive physician care versus episodic physician care. Comprehensive health care must be defined more broadly than just physician care and should include social and psychiatric (mental health) in addition to the usual medical, nursing, and dental health care.

Secondly, it is important to consider the difference between comprehensive and episodic care. The latter is disease oriented, and the former is health promoting, and it is difficult to compare the two when one talks about a chronic disease and compliance.

Dr, GORDIS: In response to your first question, it seems to me that in analyzing comprehensive care we have to study each of the components that go into it—each component individually as well as all the components together—if we are to find which factors are critical and which factors are extraneous. Although it is true that this study focused only on comprehensive care by a physician, the care was not restricted to a single organ system or set of problems. But I am in full agreement with you that different types of studies should also be done, including those of other health professionals, and in different settings.

As far as it being disease oriented, I agree with you there, too. The problem is that the research in this area cannot be done cosmically; we must isolate the specific factors which we wish to analyze, and submit them to rigorous evaluation. I would suggest, therefore, that this type of study should be extended to preventive health services and health care, as well as to chronic disease management.

WILLIAM OBRINSKY (Montefiore Hospital, New York, N.Y.): Comprehensive care is a way of life. It is not something that you can decide on one day to turn on, and a year later to turn off. You have had a population that has never had any experience with comprehensive care, and it takes a lot longer than 1 year to begin to teach the principles of comprehensive care. I would be very much interested in a similar study that might be done with a population who from very early infancy had comprehensive care over a longer period than 1 year.

JOEL J.ALPERT (Children's Hospital Medical Center, Harvard Medical School, Boston, Mass.): Dr. GORDIS, I agree with your expressed philosophy very much. We need controlled evaluations of comprehensive care. The challenge, however, is not only to try to measure differences but also to offer explanations as to why differences were or were not found. Thus, other points might be that these were families that were engaged in an identical physical place; that this was care given to individual patients and not to families.

Your report is very similar to some of our own work. We did not measure differences in the first year of our study on 551 families but saw differences in the second and third.

We also found that many of these measured differences disappeared in the third year of the study and these disappearing differences were due to those families on welfare who were pulled back into what we call the welfare-fragmented system by pressures outside of the comprehensive care program. What may, indeed, be needed is a total change in the health care system. Perhaps you have also identified a very complex population. I wonder how many of your 77 patients were on welfare.

Dr. GORDIS: Only a relatively small proportion were on welfare, but the group was too small to be able to subject it to this type of analysis.

I would like to make it clear that we are not suggesting that the lack of positive findings here applies to comprehensive care programs in general. We suggest only that this approach be used to submit comprehensive care to a truly rigorous evaluation of its effectiveness.

BARBARA M. KORSCH (Children's Hospital, Los Angeles, Calif.): If, as has been stated, this may not have been an example of truly comprehensive care, in that it was not delivered by a health team and did not start at birth, on the other hand, it did seem to isolate the factor of continuous medical care by one physician. Here again, it seems to me that there are other studies, like the one by CHARNEY et al. where continuous care by a particular pediatrician did seem to make for increased compliance with various medical regimes studied previously.

So it is not a simple situation, even if you say that you are simply introducing the factor of the continuous relationship with a doctor. The question is: Can you legislate this in a hospital setting at one moment, and produce a change, or can you not?

To document the study, you may need larger numbers of cases, because in our earlier work on compliance with medical advice we did have some very discouraging months during the first few hundred cases, and finally the zeros before the ones began to appear after we were well beyond 600 or 700 patients. This was an outpatient department. I do not think that the findings in this number necessarily mean that you might not get a real difference.

There are several other points that interested me. I would be very curious to do some studies on the actual interaction between the physicians in the two systems and their patients, because our work has shown some statistically significant differences in patients following medical advice which could be predicted on the basis of specific attributes of an individual interaction of a new physician with a new patient around an illness, and I would be curious to see how the physicians in the two groups relate to patients, and how they communicate with their patients.

Finally, lest someone get the impression that the fact of having a continuous relationship with a doctor like this does not improve patients' follow-through on medical advice. When we started our studies we had done some work that suggested that perhaps the social distance between the physician and the patient might make the patient more compliant, in the sense that he is a big authority, and you cannot get too close to him, and maybe what he says might be more important, and therefore you were anxious to do what he said. We found exactly the opposite to be true in our compliance study; namely, that effect, and friendliness, and conversation other than strictly medical conversation, had a positive effect on compliance.

EDGAR J.SCHOEN (Kaiser Foundation Hospital, Oakland, Calif.): The authors considered they were delivering comprehensive care. Did the patients?

You mentioned that two senior residents were used. What was the total number of physicians involved in this work? Also, at the end of the study, were the patients asked at any point if they knew the name of their doctor?

Dr. GORDIS: The same two physicians provided all the care for the comprehensive care group. In response to your second question, on the identification of the physician by the patient, there were significant differences between the two groups in the percentage of who could correctly identify their physician by name.

NICHOLAS M.NELSON (Boston, Mass.): I would like to suggest that your slide which showed an increase in noncompliance in both the experimental and control groups is yet another demonstration of the uncertainty principle, or as it is sometimes known, the Hawthorne effect; namely, that it is impossible to observe the phenomenon without changing the phenomenon observed.

President DAY: I think we will have to close the discussion.

Log in or create a free account to read this content

Gain free access to this article, as well as selected content from this journal and more on nature.com

Access through your institution

or

Sign in or create an account

Continue with Google

Continue with ORCiD