THE DOCTOR WILL SEE YOU EVENTUALLY

Of all the problems with the U.S. health-care system, one of the most vexing for patients is simply sitting in the doctor's waiting room. Being ushered into the exam room, only to be left shivering in a paper gown, to wait some more, adds to the aggravation. It's the health-care equivalent of being stuck on the tarmac in a crowded plane.

The average time patients spend waiting to see a health-care provider is 22 minutes, and some waits stretch for hours, according to a 2009 report by Press Ganey Associates, a health-care consulting firm, which surveyed 2.4 million patients at more than 10,000 locations. Orthopedists have the longest waits, at 29 minutes; dermatologists the shortest, at 20. The report also noted that patient satisfaction dropped significantly with each five minutes of waiting time.

Physicians rightly bristle that they aren't serving french fries. Patients are different, and their needs are unpredictable. What's more, doctors say that fee-for-service medicine with low reimbursement rates forces them to keep packing more patients into each day, compounding the opportunity for delays.

"I live my life in seven-minute intervals," says Laurie Green, a obstetrician-gynecologist in San Francisco who delivers 400 to 500 babies a year and says she needs to bring in $70 every 15 minutes just to meet her office overhead.

Some practices, like Dr. Green's, pride themselves on running efficiently, and others are finding ways to streamline office-traffic flow and cut waiting time. "Patients' time is valuable. I think practitioners understand that more and more," says Andre W. Renna, executive director of a group of 14 gastroenterologists in Lancaster, Pa. He says even the term "waiting room" has a bad connotation. Many offices prefer "reception area" instead.

Some steps to reduce patient wait times are as simple as leaving a few "catch-up" slots empty each day or stocking the same supplies in the same place in every exam room. "That way, doctors don't have to stick their heads out the door and ask where things are. It saves a lot of time," says L. Gordon Moore, a family physician and faculty member of the Institute for Healthcare Improvement, a Cambridge, Mass.-based non-profit group that advises medical practices.

Cutting waiting times is also part of the movement toward turning primary-care practices into what reformers call "patient-centered medical homes."

For now, patients themselves can minimize waits by asking for the first appointment of the day or right after lunch, when doctors are least likely to be backed up.

Measures the health-care industry is trying or reviewing include:

"Open-access" scheduling: Doctors used to think that having their appointments booked weeks in advance was a mark of prestige. It can also make for delays. Patients scheduled far in advance often cancel or fail to show. So offices, like airlines, tend to overbook, then struggle to fit everyone in.

"Those things have ripple effects, and the barometer is the waiting room," says Terry McGeeney, president and CEO, of TransforMED, a subsidiary of the American Academy of Family Physicians (AAFP) working to improve medical-practice design.

Instead, the AAFP and other primary-care groups now urge practices to leave as much as 70% of their schedules open for same-day appointments. Patients with immediate concerns are more likely to show up, on time, and stick to the point. "When patients think they may not be back in for a few months, they have a tendency to say, 'Can we also talk about this other thing?' so what should have been a 15-minute appointment ends up to being 30," Dr. McGeeney says.

Efficient offices also monitor their ebbs and flows in patient traffic and leave more slots open, say, on Mondays and Fridays and during flu season.

Switching to open-access scheduling can take months of transition time, and some doctors worry that appointment slots will go unfilled. "But the reality is you have the same number of patients and the same number of problems," says Dr. McGeeney. "And over time, patients flow through the office much more quickly."

Minimize office visits: Many follow-up doctor visits could easily be handled via phone, email or video chat. But in the past, doctors had to have patients return to the office in order to get reimbursed for their time and expertise. Now some insurers are beginning to cover nontraditional visits, including phone consultations in some circumstances. "I think we'll even get to the point where we'll have some of these visits by smartphone," says Douglas Wood, chairman of health-care policy and research at the Mayo Clinic in Rochester, Minn.

Advance prep: Having patients complete registration forms, medication lists and other paperwork in advance, via computer or mail, can also speed office visits considerably. So does having a receptionist or nurse make sure that all necessary test results and records have been received before the patient arrives.
Self Scheduling

Some pilot programs even let patients schedule their own visits via computer, minimizing overbooking and making patients more aware of a doctor's time constraints. "Some patients say, 'Hey, it's getting close to 11:30. I better wrap it up,'" Dr. Moore says.

Huddling up: Some of the unpredictability practices face actually is predictable if practices know their patients well.

"Here's Mr. So and So. He's in a 15-minute slot, but we know he's a 45-minute guy," says Dr. Moore. "Or Mrs. Jones is bringing in a kid with a sore throat. But we know she always brings in the other three."

By reviewing the upcoming patient list several times a day, doctors and other staffers can anticipate and plan around some delays.

Teamwork: Many primary-care physicians spend much of the day doing tasks that other staffers could do, experts say. If the practice is big enough, nurse practitioners, medical assistants and other "physician extenders" could handle many aspects of patient care and cut waiting time, while the doctor is busy elsewhere. "In my office, everyone has a flu shot before I even get in the room," says Melissa Gerdes, a family physician in Whitehouse, Texas, who was part of a TransforMED pilot project.

Cutting "cycle time": In medical jargon, "cycle time" refers to the period from when a patient first arrives at the office until departure. Many practices are making a point to measure and reduce it. In Dr. Gerdes's demonstration project, patients themselves were given clipboards to record each phase of the visit, from when they arrived at the office, time in the waiting and exam rooms, time with the physician and time checking out. By identifying bottlenecks, she and her colleagues were able to cut about 12 minutes from the typical 40 minutes per hour.

"It did two things. It taught us how we were doing, but it also communicated to the patients that we were serious about improving," Dr. Gerdes says.

Keep patients informed: Simply keeping waiting patients informed about delays—and giving them the option to reschedule—can also go a long way. "It's just like sitting on an airplane—you want the pilot to tell you what's going on and what to expect," says Roland Goertz, president of the AAFP.
Tracking Apps

To that end, some practices now use automated programs to notify patients when they're behind schedule, even before patients get to the office. One Web-based tool, called MedWaitTime, lets patients check how late the doctor is running, much like airline passengers can get a flight-update. But it does require office staffers to manually update the information.

How we doing? Experts urge practices to periodically survey their patients to find out what they think about the office's efficiency. A simple note card asking them to rate aspects of the visit can yield some surprising insights.

A program called HowsYourHealth.org, designed by Dartmouth Medical School professor John H. Wasson, provides a detailed online questionnaire for patients to evaluate doctors' practices and give more detailed information about their own that can be integrated into the offices' electronic-medical records. The system, which is free for patients and a nominal $350 for practices, also allows doctors to compare their office scores with national averages and share ideas with other practices.

"It's really a combination of common sense, mathematics and eliminating stupid practices," Dr. Wasson says.
OCTOBER 19, 2010 Wallstreet Journal; Health Journal

EFFECTS OF DIET AND PHYSICAL ACTIVITY INTERVENTIONS

Date Posted: October 12, 2010
Authors: Goodpaster BH, DeLany JP, Otto AD, et al.
Citation: JAMA 2010;Oct 9:[Epub ahead of print].



Question:
What are the effects of weight loss and physical activity intervention on the adverse health risks of severe obesity?

Methods:
A single-blind randomized trial was conducted from February 2007 through April 2010 at the University of Pittsburgh. Participants were 130 (37% African American) severely obese (class II or III) adult participants without diabetes recruited from the community. Patients were provided a 1-year intensive lifestyle intervention consisting of diet and physical activity. One group (initial physical activity) was randomized to diet and physical activity for the entire 12 months; the other group (delayed physical activity) had the identical dietary intervention, but with physical activity delayed for 6 months. Primary outcome was change in weight. Secondary outcomes were additional components comprising cardiometabolic risk, including waist circumference, abdominal adipose tissue, and hepatic fat content.

Results:
There was no difference between groups for: mean age 46 years, 10% men, mean body mass index 43.5 kg/m2, and 75% had class III obesity. Of 130 participants randomized, 101 (78%) completed the 12-month follow-up assessments. Although both intervention groups lost a significant amount of weight at 6 months, the initial-activity group lost significantly more weight in the first 6 months compared with the delayed-activity group (10.9 kg, 95% confidence interval [CI], 9.1-12.7 vs. 8.2 kg, 95% CI, 6.4-9.9; p = 0.02 for group × time interaction). Weight loss at 12 months, however, was similar in the two groups (12.1 kg, 95% CI, 10.0-14.2 vs. 9.9 kg, 95% CI, 8.0-11.7; p = 0.25 for group × time interaction). Waist circumference, visceral abdominal fat, hepatic fat content, blood pressure, and insulin resistance were all reduced in both groups. The addition of physical activity promoted greater reductions in waist circumference and hepatic fat content.

Conclusions:
Among patients with severe obesity, a lifestyle intervention involving diet combined with initial or delayed initiation of physical activity resulted in clinically significant weight loss and favorable changes in cardiometabolic risk factors.

Perspective:
The findings are intuitive. Experience in our center is that patients who commit to both exercise and diet do better with weight loss and metabolic parameters, at least in part because of improved diet compliance in those who exercise

WOMEN WITH DEMANDING JOBS 40% MORE LIKLEY TO HAVE HEART ATTACK, STROKE

The CBS Evening News (11/14, story 11, 0:20, Mitchell) reported, "Findings of the longest major study on stress in women are in this evening. The 10-year study found women with demanding jobs were 40% more likely to have a heart attack or stroke as women with less stressful jobs."

The AP (11/14) reported that the study presented at the American Heart Association conference on Nov. 14 followed "17,415 participants in the Women's Health Study" for 10 years. The investigators then discovered that "women with demanding jobs and little control over how to do them were nearly twice as likely to have suffered a heart attack as women with less demanding jobs and more control."

"Women with high-stress jobs face about 88 percent more risk of a heart attack than if they had low workplace strain," Bloomberg News (11/14, Lopatto) reported. The study authors "defined the stressful positions as those with demanding tasks and little authority or creativity," Bloomberg News noted. HealthDay (11/14, Gardner), the Los Angeles Times (11/14, Roan) "Booster Shots" blog, BBC News (11/15), CNN /Health.com (11/14, Harding), and the UK's Daily Mail (11/15, Borland) also covered the story.

TESTOSTERONE THERAPY IN WOMEN WITH CHRONIC HEART FAILURE

A Pilot Double-Blind, Randomized, Placebo-Controlled Study
JACC 10-10

Objectives:
The primary objective of this study was to assess the effect of a 6-month testosterone supplementation therapy on functional capacity and insulin resistance in female patients with chronic heart failure (CHF).
Background: Patients with CHF show decreased exercise capacity and insulin sensitivity. Testosterone supplementation improves these variables in men with CHF. No study has evaluated the effects of testosterone supplementation on female patients with CHF.

Methods:
Thirty-six elderly female patients with stable CHF, (ejection fraction 32.9 ± 6) were randomly assigned (2:1 ratio) to receive testosterone transdermal patch (T group, n = 24) or placebo (P group, n = 12), both on top of optimal medical therapy. At baseline and after 6 months, patients underwent 6-min walking test (6MWT), cardiopulmonary exercise test, echocardiogram, quadriceps maximal isometric voluntary contraction, dynamic quadriceps isokinetic strength (peak torque), and insulin resistance assessment by homeostasis model.

Results:
Distance walked at 6MWT as well as peak oxygen consumption significantly improved in the T group, whereas they were unchanged in the P group (p < 0.05 for all comparisons). The homeostasis model was significantly reduced in the T group in comparison with the P group (-16.5% vs. +5%, respectively; p < 0.05). Maximal voluntary contraction and peak torque increased significantly in the T group but did not change in the P group. Increase in distance walked at 6MWT was related to the increase in free testosterone levels (r = 0.593, p = 0.01). No significant changes in echocardiographic parameters were observed in either group. No side effects requiring discontinuation of T were detected.

Conclusions:
Testosterone supplementation improves functional capacity, insulin resistance, and muscle strength in women with advanced CHF. Testosterone seems to be an effective and safe therapy for elderly women with CHF.