Skip to main content

Main menu

  • Home
  • Content
    • Current Issue
    • Online First
    • Multimedia
    • Collections
    • Past Issues
    • Articles by Subject
    • Articles by Type
    • Supplements
    • The Issue in Brief (Plain Language Summaries)
    • Call for Papers
  • Info for
    • Authors
    • Reviewers
    • Media
    • Job Seekers
  • About
    • Annals of Family Medicine
    • Editorial Staff & Boards
    • Sponsoring Organizations
    • Copyrights & Permissions
    • Announcements
  • Engage
    • Engage
    • e-Letters (Comments)
    • Subscribe
    • RSS
    • Email Alerts
    • Journal Club
  • Contact
    • Feedback
    • Contact Us
  • Careers

User menu

  • My alerts

Search

  • Advanced search
Annals of Family Medicine
  • My alerts
Annals of Family Medicine

Advanced Search

  • Home
  • Content
    • Current Issue
    • Online First
    • Multimedia
    • Collections
    • Past Issues
    • Articles by Subject
    • Articles by Type
    • Supplements
    • The Issue in Brief (Plain Language Summaries)
    • Call for Papers
  • Info for
    • Authors
    • Reviewers
    • Media
    • Job Seekers
  • About
    • Annals of Family Medicine
    • Editorial Staff & Boards
    • Sponsoring Organizations
    • Copyrights & Permissions
    • Announcements
  • Engage
    • Engage
    • e-Letters (Comments)
    • Subscribe
    • RSS
    • Email Alerts
    • Journal Club
  • Contact
    • Feedback
    • Contact Us
  • Careers
  • Follow annalsfm on Twitter
  • Visit annalsfm on Facebook
EditorialEditorials

In This Issue: Size Matters

Kurt C. Stange
The Annals of Family Medicine January 2016, 14 (1) 2-3; DOI: https://doi.org/10.1370/afm.1895
Kurt C. Stange
Roles: Editor
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • Article
  • Info & Metrics
  • eLetters
  • PDF
Loading

This issue of Annals examines matters of practice and panel size, use of technology by patients and clinicians, new ways of assessing home blood pressures and conducting research, high-risk patient groups, and reflective insights from practicing family physicians.

ALTERNATIVES TO HOSPITAL-DOMINATED VERTICALLY INTEGRATED SYSTEMS

For decades, pundits have predicted the demise of solo and small practices, and health care systems have been pushing policies that hasten their demise. And yet, small practices persist. A study by Liaw et al finds that most family physicians seeking board certification are in small and solo practices. Small practices constitute the largest category of practice size among physicians providing care in rural areas, and small or solo practice is more common among African American, Hispanic, and more experienced physicians.1 Medical home status and having a care coordinator are more common as practice size increases.

This research shows that amidst the rush toward increasing scale, which requires complicated, explicit, and often klunky systems, it may be important to not devalue smaller, local levels of scale in which simple, personal, often implicit systems may function well and meet the particular needs of both practitioners and disadvantaged populations. An editorial by Mostashari highlights the potentially vital role for small practices in a rapidly changing health care system.2 In another editorial, Glancey and Kennedy share an on-the-ground view of quality and payment from the perspective of an idealized micro practice.3

The opposite end of the size spectrum is revealed in a study by Casalino and colleagues, who identified and studied large, independent primary care medical groups.4 The size of these groups presents an opportunity for economies of scale, but what makes these practices particularly interesting is the combination of size and physician ownership. This gives them power to not only organize primary care, but to be an effective patient-focused force in organizing care and in selectively engaging narrowly focused care that is often both high risk and high cost. Large systems run by hospitals have very different incentives and perspectives.

A population-based study by Dahrouge examines the association of family physicians’ panel sizes with quality of care and health service use.5 The complex findings are worthy of thoughtful interpretation. Among small practices, greater panel size is associated with slightly lower cancer screening and comprehensiveness of care, little difference in chronic disease management quality, greater hospitalization rates for ambulatory care-sensitive conditions, and lower rates of non-urgent emergency department visits. Continuity of care is highest with medium panel sizes. Clearly, practice panel size has complex effects, or at least correlates, that depend on local context and other factors.

What both small and very large independent practices have in common is an on-the-ground focus on the whole person. Their presence is a threat to the hegemony of hospital-dominated systems. Such systems can use their power to vertically integrate care, but are conflicted in providing patient-centered care when they compete over providing high-risk, high-cost care commodities, and are paid more to perform procedures than to focus holistically on patient needs. Even with more value-based payment, large hospital-dominated systems require very complex systems in order to perform the integrating, personalizing, prioritizing functions that are efficiently and effectively performed by primary care.6 Before it is too late to diversify the headlong rush toward a monoculture of vertically integrated, hospital-dominated systems, it is worth broadening the ideology and ecology of reform to test the hypothesis that higher-value personalization, integration, and sustainability may be provided by horizontally integrated systems based on independent large and small primary care practices that are well linked with mental health care and public health, and that selectively purchase vertical integration from hospitals and specialists.7–11

TECHNOLOGY SUPPORTING PATIENTS, CLINICIANS, AND COMMUNICATION

In a nationally representative sample, Serrano and colleagues identify a gradient of patients’ willingness to exchange different kinds of information using mobile devices, and the characteristics of patients willing to engage in different kinds of electronic health information interchange.12 This is useful information for designing and implementing electronic information systems to meet the needs of different types of patients.

HIGH-RISK GROUPS

Among 3 durations of opioid use, Scherrer et al find that longer duration of use is associated with new onset of depression, whereas shorter durations (and dose) are not associated with incident depression.13

Another interesting incidence study finds a high rate of new depressive symptoms in a consecutive sample of adult patients presenting for care in primary care practices in a Hong Kong practice-based research network. The rate of incident depression is lower among patients seen by physicians with qualifications in both family medicine and psychological medicine, implying the possibility of a preventive benefit of seeing clinicians with joint training.14

Asgary and colleagues find a very high rate of uncontrolled hypertension among adults using homeless shelters.15 Interestingly, those with multiple chronic conditions have better hypertension control, as do those with insurance.

NEW METHODS FOR ASSESSING HOME BLOOD PRESSURE AND FOR STUDYING DIVERSE GROUPS

Until now, clinicians have not had an empirically validated method for assessing a patient’s home blood pressure beyond informally looking over a list of home blood pressure readings. The study by Sharman et al, featured in Annals Journal Club, finds that the percentage of the last 10 home systolic blood pressures ≥135 mm HG provides a reasonable estimate of the reference standard of 24-hour ambulatory blood pressure.16

In the research realm, Fetters et al develop a novel split-session method for conducting focus groups, in which time is divided between sessions with the entire group and with subgroups.17 The researchers find this method useful in a specific application to studying physicians and staff members in primary care practices.

REFLECTIONS FROM EXPERIENCE

Two essayists share wisdom from lives in practice.

Ventres shares, in both written and video formats,18 his personal ethos of healing. For Shani, a tempestuous patient stirs up a storm and wise reflections from his physician on the meaning of sleepless nights.19

We welcome your reflections at http://www.AnnFamMed.org.

  • © 2016 Annals of Family Medicine, Inc.

References

  1. ↵
    1. Liaw WR,
    2. Jetty A,
    3. Petterson S,
    4. Peterson LE,
    5. Bazemore A
    . Solo and small practices: a vital, diverse part of primary care. Ann Fam Med. 2016;14(1):8–15.
    OpenUrlAbstract/FREE Full Text
  2. ↵
    1. Mostashari F
    . The paradox of size: how small, independent practices can thrive in value-based care. Ann Fam Med. 2016;14(1):5–7.
    OpenUrlFREE Full Text
  3. ↵
    1. Glancey KK,
    2. Kennedy JG
    . Achieving PCMH status may not be meaningful for small practices. Ann Fam Med. 2016;14(1):4–5.
    OpenUrlFREE Full Text
  4. ↵
    1. Casalino LP,
    2. Chen MA,
    3. Staub CT,
    4. Press MJ,
    5. Mendelsohn JL,
    6. Lynch JT,
    7. Miranda Y
    . Large independent primary care medical groups. Ann Fam Med. 2016;14(1):16–25.
    OpenUrlAbstract/FREE Full Text
  5. ↵
    1. Dahrouge S,
    2. Hogg W,
    3. Younger J,
    4. Muggah E,
    5. Russell G,
    6. Glazier RH
    . Primary care physician panel size and quality of care: a population-based study in Ontario, Canada. Ann Fam Med. 2016;14(1):26–33.
    OpenUrlAbstract/FREE Full Text
  6. ↵
    1. Starfield B,
    2. Shi LY,
    3. Macinko J
    . Contribution of primary care to health systems and health. Milbank Q. 2005;83(3):457–502.
    OpenUrlCrossRefPubMed
  7. ↵
    1. De Maeseneer J,
    2. van Weel C,
    3. Egilman D,
    4. Mfenyana K,
    5. Kaufman A,
    6. Sewankambo N
    . Strengthening primary care: addressing the disparity between vertical and horizontal investment. Br. J. Gen. Pract. 2008;58(546):3–4.
    OpenUrlFREE Full Text
    1. Thomas P,
    2. Meads G,
    3. Moustafa A,
    4. Nazareth I,
    5. Stange KC
    . Combined horizontal and vertical integration of care: a goal of practice-based commissioning. Qual Prim Care. 2008;16(6):425–432.
    OpenUrlPubMed
    1. Robinson JC,
    2. Miller K
    . Total expenditures per patient in hospital-owned and physician-owned physician organizations in California. JAMA. 2014;312(16):1663–1669.
    OpenUrlCrossRefPubMed
    1. Casalino LP,
    2. Pesko MF,
    3. Ryan AM,
    4. et al
    . Small primary care physician practices have low rates of preventable hospital admissions. Health Aff. (Millwood). 2014;33(9):1680–1688.
    OpenUrlAbstract/FREE Full Text
  8. ↵
    1. Baker LC,
    2. Bundorf MK,
    3. Kessler DP
    . Vertical integration: hospital ownership of physician practices is associated with higher prices and spending. Health Aff. (Millwood). 2014;33(5):756–763.
    OpenUrlAbstract/FREE Full Text
  9. ↵
    1. Serrano KJ,
    2. Yu M,
    3. Riley W,
    4. et al
    . Willingness to exchange health information via mobile devices: findings from a population-based survey. Ann Fam Med. 2016;14(1):34–40.
    OpenUrlAbstract/FREE Full Text
  10. ↵
    1. Scherrer JF,
    2. Salas J,
    3. Copeland L,
    4. et al
    . Prescription opioid duration, dose and increased risk of depression in 3 large patient populations. Ann Fam Med. 2016;14(1):54–62.
    OpenUrlAbstract/FREE Full Text
  11. ↵
    1. Chin W,
    2. Wan E,
    3. Choi E,
    4. Chan K,
    5. Lam C
    . The 12-month incidence and predictors of PHQ-9–screened depressive symptoms in Chinese primary care patients. Ann Fam Med. 2016;14(1):47–53.
    OpenUrlAbstract/FREE Full Text
  12. ↵
    1. Asgary R,
    2. Alcabes A,
    3. Naderi R,
    4. Schoenthaler A,
    5. Ogedegbe O,
    6. Sckell B
    . Rates and predictors of uncontrolled hypertension among hypertensive homeless adults using New York City shelter-based clinics. Ann Fam Med. 2016;14(1):41–46.
    OpenUrlAbstract/FREE Full Text
  13. ↵
    1. Sharman JE,
    2. Blizzard L,
    3. Kosmala W,
    4. Nelson M
    . Pragmatic method to assess blood pressure control from home blood pressure diaries. Ann Fam Med. 2016;14(1):63–69.
    OpenUrlAbstract/FREE Full Text
  14. ↵
    1. Fetters MD,
    2. Guetterman TC,
    3. Power D,
    4. Nease DE
    . Split-session focus group interviews in the naturalistic setting of family medicine offices. Ann Fam Med. 2016;14(1):70–75.
    OpenUrlAbstract/FREE Full Text
  15. ↵
    1. Ventres W
    . Healing. Ann Fam Med. 2016;14(1):76–78.
    OpenUrlAbstract/FREE Full Text
  16. ↵
    1. Shani M
    . White nights. Ann Fam Med. 2016;14(1):79–80.
    OpenUrlAbstract/FREE Full Text
PreviousNext
Back to top

In this issue

The Annals of Family Medicine: 14 (1)
The Annals of Family Medicine: 14 (1)
Vol. 14, Issue 1
January/February 2016
  • Table of Contents
  • Index by author
  • Back Matter (PDF)
  • Front Matter (PDF)
  • In Brief
Print
Download PDF
Article Alerts
Sign In to Email Alerts with your Email Address
Email Article

Thank you for your interest in spreading the word on Annals of Family Medicine.

NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. We do not capture any email address.

Enter multiple addresses on separate lines or separate them with commas.
In This Issue: Size Matters
(Your Name) has sent you a message from Annals of Family Medicine
(Your Name) thought you would like to see the Annals of Family Medicine web site.
CAPTCHA
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
4 + 14 =
Solve this simple math problem and enter the result. E.g. for 1+3, enter 4.
Citation Tools
In This Issue: Size Matters
Kurt C. Stange
The Annals of Family Medicine Jan 2016, 14 (1) 2-3; DOI: 10.1370/afm.1895

Citation Manager Formats

  • BibTeX
  • Bookends
  • EasyBib
  • EndNote (tagged)
  • EndNote 8 (xml)
  • Medlars
  • Mendeley
  • Papers
  • RefWorks Tagged
  • Ref Manager
  • RIS
  • Zotero
Get Permissions
Share
In This Issue: Size Matters
Kurt C. Stange
The Annals of Family Medicine Jan 2016, 14 (1) 2-3; DOI: 10.1370/afm.1895
Reddit logo Twitter logo Facebook logo Mendeley logo
  • Tweet Widget
  • Facebook Like
  • Google Plus One

Jump to section

  • Article
    • ALTERNATIVES TO HOSPITAL-DOMINATED VERTICALLY INTEGRATED SYSTEMS
    • TECHNOLOGY SUPPORTING PATIENTS, CLINICIANS, AND COMMUNICATION
    • HIGH-RISK GROUPS
    • NEW METHODS FOR ASSESSING HOME BLOOD PRESSURE AND FOR STUDYING DIVERSE GROUPS
    • REFLECTIONS FROM EXPERIENCE
    • References
  • Info & Metrics
  • eLetters
  • PDF

Related Articles

  • No related articles found.
  • Google Scholar

Cited By...

  • No citing articles found.
  • Google Scholar

More in this TOC Section

  • Recruiting, Educating, and Taking Primary Care to Rural Communities
  • Returning to a Patient-Centered Approach in the Management of Hypothyroidism
  • An Opportunity to Emphasize Equity, Social Determinants, and Prevention in Primary Care
Show more Editorials

Similar Articles

Content

  • Current Issue
  • Past Issues
  • Past Issues in Brief
  • Multimedia
  • Articles by Type
  • Articles by Subject
  • Multimedia
  • Supplements
  • Online First
  • Calls for Papers

Info for

  • Authors
  • Reviewers
  • Media
  • Job Seekers

Engage

  • E-mail Alerts
  • e-Letters (Comments)
  • RSS
  • Journal Club
  • Submit a Manuscript
  • Subscribe
  • Family Medicine Careers

About

  • About Us
  • Editorial Board & Staff
  • Sponsoring Organizations
  • Copyrights & Permissions
  • Contact Us
  • eLetter/Comments Policy

© 2023 Annals of Family Medicine