Is There Time for Management of Patients With Chronic Diseases in Primary Care?

Following practice guidelines is certainly possible if one is willing to see fewer patients each day. I spent 20 years in the office trying to see 30- 40 patients each day, working 12 hour days but never having enough time with patients. My wife and I moved from a small city in southern Michigan to rural northern Michigan in 2003, after I sold my conventional practice (with 4000 patients and 12 employees including two wonderful Nurse Practitioners) to two young doctors. We now stay busy providing care to about 500 patients with no office and no employees. Most of the families we see don't have health insurance so we have to keep our costs down. I spend the mornings doing computer work and building the day's schedule, and we usually see 6-10 patients each afternoon (1-2 patients per hour) driving from home to workplace to Adult Foster Care to visit patients wherever they are; I'm also on staff at two area hospitals. Our electronic records are geared to preventive care and careful followup, though we do a fair amount of "urgent care" work (sick kids, vacationers, occasional suturing). It did take a year to break even in the new practice since we were unknown in the county and people said "doctors don't make housecalls," but now we are turning patients away and seeking more board-certified physicians to work in nearby communities. The insurers are happy to pay for our services. Hundreds of other practices are primarily making housecalls nowadays, many listed on the American Academy of Home Care Physicians website at www.aahcp.org. Details on our practice are available at www.BearLakeDoctor.com.

Robert Shannon, M.D.

Competing interests:   None declared

The article by Østbye, et al. is an interesting approach to a problem long known to guideline developers. As guidelines are developed for individual conditions, it may be possible to look that the costs and benefits of the alternatives. However, there is no good method for evaluating the overall impact of guidelines on the total healthcare budget. Since society has made no decision on the overall healthcare budget, most guidelines either ignore economic impacts or at best use some arbitrary $/QALY ratio as a proxy for a budget constraint.

In this article, the authors have selected their own arbitrary budget constraint by making two assumptions: 1) Primary care physicians will have a panel size of 2500, and 2) primary care physicians will provide all recurring care for chronic conditions. Given those constraints, the authors attempt to show that the selected guidelines are too costly (in terms of time).

Neither of these assumptions is immutable. As noted by the authors and in the posted comments, some of the recommended interventions could be performed by auxiliary staff. Also not all patients with chronic conditions receive all of their care from their primary care providers. Specialists do provide care for chronic conditions, particularly for difficult to manage patients.

Panel size also is not fixed. One of the aims of many guidelines for chronic conditions is to reduce long term complications or exacerbations of the condition and hence reduce overall healthcare use. Certainly, some, if not most, of the care for these complications/exacerbations comes from specialists. If the guidelines are successful, reductions in specialty care needs could result in shifts in physician counts to primary care reducing panel size. Moreover, panel size could be reduced because society is willing to pay for the extra care.

The authors used a rough analysis to reach their time estimates. As they indicate, the actual visit times and the impact of co-morbidities are unknown. Even more problematic is the assumption that patients who are not under control stay that way. It seems likely that with all those visits, many patients would have improved control and the number of visits required would drop sharply.

I believe it is very important to consider resources when doing guidelines and it is unfortunate that many specialty societies choose not to include them in their analyses. However, I believe the present analysis is insufficient to warrant a recommendation that we can’t afford the current guidelines.

Competing interests:   consultant for specialty societies in guideline creation, formerly AAFP manager for guidelines

Bravo to Ostbye and colleagues for giving some objective clarity to a issue we have all had strong feeling about. Guidelines tend to be developed by people who are very interested in a specific problem (even if they are Family Physicians!) and there are few if any attempts to evaluate guidelines as to whether they make sense; sense for physicians and sense for patients. The real questions is "What is the value of any particular guideline. This paper is effective at documenting the "cost" of guidelines in terms of physician (or at least clinic) time. However, much remains to be done. I hope the authors persue this line of inquiry to answer such questions as: What is the financial cost? What is the cost to patients if they actually do their part in following guidelines? Then we need to ascertain the benefits. What is the absolute (not just relative) risk reduction? What is the NNT for a given positive result? What is the NNH (e.g. hypoglycemic reactions or even just "hassles" for DM?) Is there good evidence supporting it? This would then let us calculate a realistic value (benefit divided by cost) for following the guideline -- value for the patient primarily but also for the physician and the health care system.

Competing interests:   None declared

When “guidelines” first appeared, many practicing physicians feared that these would soon become requirements, minimum standards, a basis for compensation and bonuses, and the standard in the courts. Our fears are being borne out. I am not against guidelines. They are necessary. They provide a gold standard for which to strive. They help my patients understand the targets for control. They assure that my partners, and my consultants, and I are all working toward the same goals.

This article presents a Kafka-like parody ( 1 ) of real practice in which the doctor has too many patients to manage (2,500) ( 2 ), too many checkmarks to document, and too little time in which to do it.

What do good family doctors really do? Primary care is defined in terms of continuity, comprehensiveness and access. It is our job to build, nurture and maintain relationships. This goes way beyond guidelines and preventive medicine. Family medicine is not merely the sum of our checkmarks. Family Medicine demands intuition and creativity to flexibly and spontaneously modify goals and treatment options. To do this, we must know our patients. We must establish and foster and ENJOY our relationships. A portion of every visit must focus on this end. It becomes easier as the relationship grows. Our worth as family doctors can’t be measured by the sum of our checkmarks on guidelines lists. Our worth should be determined by “patient-years” of the functional, therapeutic relationships, successfully nurtured and maintained.

The answer is not to “dumb down” the guidelines or “caution guidelines developers to consider the time required” ( 3 ). The answer is to use them as the tool they were meant to be. Do not use them as check lists to measure quality. Rather, apply them with intuition and creativity to integrate the guidelines with other chronic disease considerations, one or two acute problems ( 4 ), family needs, work problems, ethnic preferences, chemical dependency, transportation and economic constraints, drug sensitivities, preferences for the “pink pill” or the “blue pill”, insurance restrictions, prior authorization, information from consultants and lab reports.

Don’t change the guidelines. Use them for their intended purpose. Foster and enjoy the relationship with each patient, one at a time at each visit. Use your knowledge of each patient’s personal preferences along with the guidelines to do what is most valuable and practical at the present visit and to plan for the next visit. And the next.

References

1. Kafka, Franz, The Castle. 2. Ostbye T., et. al., “Is there time for management of patients with chronic diseases in primary care?” Annals of Family Medicine, v. 3, n.3, (Table 4.) May/June 2005. 3. Ostbye T, ibid. 4. Beasley JW, Hankey TL, Erickson R, et. al. How many problems do family physicians manage at each encounter? A WreN study. Ann Fam Med. 2004; 2:405-410.

Competing interests:   None declared

Østbye et. al. have opened a very interesting and timely discussion on the delivery of quality care for the management of chronic disease. This comes at a time when many practices are retooling their delivery of services to address the financial realities of increasing costs and shrinking reimbursement for the traditional delivery of health care services.

Their model for calculating the time required for service delivery gives us a conservative insight into the time/patient visit and daily patient volume burden to be taken on by primary care physicians. Physicians are also adding clinical guideline utilization to improve quality outcomes and increase revenue through P4P incentive programs initiated or proposed by government and private insurers.

Improving compliance will increase the controlled population by decreasing visit need. However, getting the many unidentified chronic disease sufferers to acknowledge their need for adequate health insurance coverage and care will hinder achieving outcome goals and attaining expected outcome goals of decreased morbidity and mortality.

Physician resources (absolute number of physicians and their available time/energy) are a rate limiting issue.

Answers can potentially be found in patient care models or incentive programs that partner care between the physician and patient and shift some responsibility to the patient for defined disease management, and the provision of quality information from programs like the Physician Direct ePPO of Oklahoma . This type of program combines patient education and refined clinical pathways (HealthGate) that are simple and allow for individualization of care and pathway deviation. The education program will improve disease and medical management understanding in the patient population and the guidelines allowing for flexibility will be more acceptable to physicians.

Physicians need to lead the development and implementation of these programs to ensure quality care at a reasonable rate of financial return for time invested by the health care providers and expansion of coverage to patient populations currently under or inadequately insured.

Denmark, Donald. (May 2004). Patient-physician partnering to improve chronic disease care. Family practice management. Retrieved on May 29, 2005 from http://www.aafp.org/fpm/20040500/55pati.html

Retrieved on May 30, 2005 from http://www.physiciandirect.net

Retrieved on May 30, 2005 from http://www.HealthGate.com

Competing interests:   None declared