Addressing the unique challenges of inner-city practice: A direct observation study of inner-city, rural, and suburban family practices

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 outpatient 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.