Switching Doctors: Predictors of Voluntary Disenrollment from a Primary Physician's Practice
* BACKGROUND Our objective was to evaluate 8 interpersonal and structural features of care as predictors of patients' voluntary disenrollment from their primary care physician's practice.
* METHODS We performed a longitudinal observational study in which participants completed a validated questionnaire at baseline (1996) and follow-up (1999). The questionnaire measured 4 elements of the quality of physician-patient relations (communication, interpersonal treatment, physician's knowledge of the patient, and patient trust) and 4 structural features of care (access, visit-based continuity, relationship duration, and integration of care).
Study participants were insured adults who reported having a regular personal physician at baseline and who completed both baseline and follow-up questionnaires (n=4108). The outcome measured was voluntary disenrollment from the primary physician's practice between baseline and follow-up.
* RESULTS One fifth of the patients voluntarily left their primary physician's practice during the study period. When tested independently, all 8 scales significantly predicted voluntary disenrollment (P [is less than] .001), with somewhat larger effects associated with the 4 relationship quality measures. In multivariable models, a composite relationship quality factor most strongly predicted voluntary disenrollment (odds ratio [OR]=1.6; P [is less than] .001), and the 2 continuity scales also significantly predicted disenrollment (OR=1.1; P [is less than] .05). Access and integration did not significantly predict disenrollment in the presence of these variables.
* CONCLUSIONS These findings highlight the importance of relationship quality in determining patients' loyalty to a physician's practice. They suggest that in the race to the bottom line medical practices and health plans cannot afford to ignore that the essence of medical care involves the interaction of one human being with another.
* KEYWORDS Primary health care; physician-patient relations; voluntary disenrollment [non-MESH]; patient trust [non-MESH]. Or Fam Pract 2001; 50:130-136)
The presence of sustained relationships between physicians and patients is a defining characteristic of primary care. Family physicians use these relationships to acquire the depth of medical and personal knowledge about a patient that is essential to primary care practice. It is also the reason some physicians choose this area of medicine.
A substantial body of empirical research points to the value of continuity in the physician-patient relationship, particularly in primary care. The benefits of continuity have been shown to accrue in the form of cost savings, improved health outcomes, and greater satisfaction for patients and physicians.[3,15] Yet little empirical research exists to indicate the amount of physician switching that occurs in primary care or the reasons for it.
In 1976 Kastler and colleagues examined the association between patients' assessments of their care and their "doctor shopping" behavior. They found that patients' evaluations of both interpersonal and structural features of care were significantly associated with the likelihood of voluntarily changing physicians. Those authors did not attempt to determine the relative importance of the 2 domains with respect to physician switching. The cross-sectional design precluded the study from determining which factor (if either) prospectively predicted switching.
Marquis and coworkers studied the sequencing of the satisfaction-disenrollment relationship using longitudinal data from the RAND Health Insurance Experiment (HIE). The HIE data showed that...