Physician Satisfaction with Chronic Care Processes: A Cluster-Randomized Trial of Guided Care

The Patient Centred Medical Home in the US (1), quality improvement frameworks in the UK (2), multi-disciplinary practices in Canada (3) and new models of primary care in Australia(4) all bear witness to the importance policy makers place on the role of primary care in the management of chronic and complex disease. The Guided Care framework is in interesting addition to this mix of reform strategies. (5)

Marsteller et al describe the impact on physician satisfaction of an intervention where specially educated nurses are attached to primary care teams to enhance care for chronically ill older patients.

While the authors have highlighted the main limitation of the study – its small sample size, several aspects need to be considered before concluding that the intervention has a meaningful impact on the physician’s experience of chronic disease care.

Firstly, while central to the paper's thesis, the authors only touch on the complexities of the construct of physician satisfaction. Echoing remarks by another in this thread (6) who questions the impact of physician "comfort" with the program, we wonder, what effect the physicians’ expectations of the program may have on the results? Were the physicians generally overwhelmed and hoping for any help, whatever form it took? Or were they highly functioning, and hoping that Guided Care could serve as the icing on the cake of high quality care?

Our lack of understanding of what really is happening in the practice during the intervention leaves questions as to whether the outcomes follow the addition of a spare pair of skilled clinical hands, or of the fostering of a more functional practice team. Subsequent, larger trials could benefit from a control group comprising the additional of a nurse without Guided Care training.

Given that the authors claim "roles and work processes" change with such interventions, the evolution of Guided Care needs more than marginal assessments of provider satisfaction. Complex interventions in primary care are increasingly shaped by early qualitative findings. (7) The uncertainties remaining in the interpretation of studies such as Marsteller et al suggest that rigorous qualitative methods have at least as much to offer at the end of studies of organisational change as they do at the beginning. (8)

Without knowing what is happening in the practice and between those who work there, we can only guess at what is really going on.

REFERENCES
1. Stange KC, Miller WL, Nutting PA, Crabtree BF, Stewart EE, Jaen CR. Context for Understanding the National Demonstration Project and the Patient-Centered Medical Home. Ann Fam Med. May 1, 2010;8(Suppl_1):S2-8.
2. Lester H, Sharp DJ, Hobbs FD, Lakhani M. The quality and outcomes framework of the GMS contract: a quiet evolution for 2006. Br J Gen Pract. 2006 Apr;56(525):244-6.
3. Glazier RH, Redelmeier DA. Building the patient-centered medical home in Ontario. JAMA. Jun 2;303(21):2186-7.
4. Australian Government Department of Health and Ageing. GP Super Clinics. Canberra 2010 [updated 18 January, 2010; cited 2010 May 4]; Available from: http://www.health.gov.au/internet/main/publishing.nsf/Content/pacd-gpsuperclinics.
5. Marsteller JA, Hsu YJ, Reider L, Frey K, Wolff J, Boyd C, et al. Physician satisfaction with chronic care processes: a cluster-randomized trial of guided care. Ann Fam Med. Jul-Aug;8(4):308-15.
6. Chodroff C. The importance of team and leadership skills for primary care physicians. Ann Fam Med [serial on the Internet]. 2010; 8(4): Available from: http://www.annfammed.org/cgi/eletters/8/4/308.
7. Campbell NC, Murray E, Darbyshire J, Emery J, Farmer A, Griffiths F, et al. Designing and evaluating complex interventions to improve health care. BMJ. 2007 Mar 3;334(7591):455-9.
8. Cohen DJ, Crabtree BF, Etz RS, Balasubramanian BA, Donahue KE, Leviton LC, et al. Fidelity versus flexibility: translating evidence-based research into practice. Am J Prev Med. 2008 Nov;35(5 Suppl):S381-9.

Competing interests:   None declared

The study by Marsteller and colleagues is important because it provides evidence that a new model of comprehensive primary care improves communication between physicians and their patients. More productive interactions between doctor and patient are likely a crucial first step toward increasing patient activation.

Numerous studies have shown that activated patients, who understand their illnesses and have greater self-efficacy, are more likely to perform health-promoting activities, have better physical and emotional outcomes, and lower utilization of expensive health care services (1-2). This is particularly important for older adults, the majority of whom have multiple chronic conditions that demand constant self-care and responsibility and who may be less likely to take an active role in their health and to receive appropriate primary care (3). Elderly Medicare beneficiaries with multi-morbidity have high rates of hospitalization for conditions that are potentially preventable with good ambulatory care, such as volume depletion and hypertension (4).

Financial disincentives in the Medicare program currently hinder the widespread adoption of models such as Guided Care, which provide comprehensive, coordinated care and have been shown to have positive outcomes on quality of care, health-related outcomes, and efficiency (5). The health reform legislation signed this year is a start, but the health care system should be further re-oriented to reimburse providers for this kind of care and to encourage the dissemination of these initiatives.

1. Lorig KR, Ritter P, Stewart AL, Sobel DS, Brown BW,Jr, Bandura A, et al. Chronic disease self-management program: 2-year health status and health care utilization outcomes. Med Care. 2001;39(11):1217-23.
2. Mosen DM, Schmittdiel J, Hibbard J, Sobel D, Remmers C, Bellows J. Is patient activation associated with outcomes of care for adults with chronic conditions? J Ambul Care Manage. 2007;30(1):21-9.
3. Kane RL. What can improve chronic disease care? J Am Geriatr Soc. 2009;57(12):2338-45.
4. Wolff JL, Starfield B, Anderson G. Prevalence, expenditures, and complications of multiple chronic conditions in the elderly. Arch Intern Med. 2002;162(20):2269-76.
5. Boult C, Green AF, Boult LB, Pacala JT, Snyder C, Leff B. Successful models of comprehensive care for older adults with chronic conditions: Evidence for the Institute of Medicine's "Retooling for an aging America" report. J Am Geriatr Soc. 2009;57(12):2328-37.

Competing interests:   None declared

The impact on physicians of the "Guided Care" approach (GC) to improving care of chronically ill older adults is the subject of this well -constructed study, which nonetheless suffers from varied limitations described by its authors. Nonetheless, the health system is currently involved in implementation of various features of the new health reform legislation which relate to improving the quality, efficiency, and financial impact of the burgeoning numbers of persons with chronic conditions who are among the highest cost users of the system. Thus, the information in the Marsteller, et.al. piece on "Physician Satisfaction with Chronic Care Processes..." coupled with detail on other aspects of GC which have been reported on elsewhere, is particularly timely.

It comes at a time when details on structure, process, cost and patient outcomes, and acceptability to providers and patients are scarce, and effectively answers some questions, while raising many others. This is to be expected and is no different from other ground-breaking studies focused on provision of care to diverse and complex patients. Most importantly, it reassured us that neither financial, attitudinal or experiential barriers exist to broader rollout of GC, at least for the 49 physicians who completed basline questionnaires (reduced by 11 for the second wave). The vital implications of this and other GC research for recruitment and training of the personnel (physicians, nurses and others) for those who are, and will be, involved in patient care must not be overlooked and has been recognized in other comments. The detail on tasks and the patient panel capacity of the guided care nurse is equally important for workforce planning. Finally, the role of patients and their caregivers should be formalized and these persons recognized as key participants in team process and care. With the assistance of these studies, and a willingness to build on prior contributions, our nation will be better able to more effectively meet its coming demographic and legislative/regulatory demands.

Competing interests:   None declared

This further analysis of a potentially important new approach to managing older patients by primary care physicians adds to the growing evidence that "Guided Care", or some sembelance there of, migh be an important advance. Prior analyses have claimed improvementments in patient's self-reported quality of care, family members' preceptions of the quality of care, and potentially significant cost savings. The present analysis suggests primary physicians may experience greater satisfaction with Guided Care than without, which might help address the growing need to attract and retain more primary care physicians. The results however are not overly convincing. Of all the dimensions examined, only one showed a potentially "clinically significant" improvement: physician satisfaction with patient and family communications. But there are two significant anomalies in these data: this was the area in which all physicians showed the highest satisfaction at baseline; and the control group demonstrated a decline in satisfaction about equal to the degree that the intervention group showed an improvement. Whether these results are meaningful is therefore questionable. As the authors rightly point out, the study was to a significant degree underpowered by the few groups of physicians enrolled, by the limited time frame in which it was carried out, and by the lack of any attempt at "masking" responding physicians. Additional studies are surely indicated, to further validate the outcomes of this particular approach to improving the care of the chronically ill, as well as to identify those components (8 are mentioned) of the nurses responsibilities that provided the greatest benefit, and which, if any responsibilities might be dropped or added to reduce time and cost, and improve outcomes.

Competing interests:   None declared

The article by Marsteller shows higher satisfaction with communications of Guided Care Physicians and their patients compared to control physicians. In earlier reports these investigators showed cost effective care. While the physicians could not be blinded, the study is robust and has enormous face value. While the study utilized mostly geriatricians there is no reason that the results could not be generalized to all primary care providers caring for chronically ill seniors. It is a model of care delivery that is likely to be broadly dissiminated as a part of health care reform. Of course, the effectiveness of Guided Care depends greatly on the frequency and effectiveness of the communication of physician and nurse.

Competing interests:   None declared

Competing interests:   None declared

This article hightlights the importance of enhancing the skills of primary care physicians to both participate with and lead multidisciplinary teams of providers who are responsible for the complex care of frail, chronically ill elderly patients. As noted in the Introduction to their paper, "Physicians receive little specific training in providing chronic care,. . ." Likewise, most physicians have limited experience leading and participating with teams.

A physician's satisfaction in a group setting may relate to their degree of emotional comfort or cultural consistency that occurs in the group setting. If the physician has the requisite skills to effectively participate with or lead a team, the satisfaction of the physician might be higher than if they are uncertain or insecure of their role and function in the team setting.

According to Patrick Lencioni in "The Five Dysfunctions of a Team," the skills necessary for a highly functioning team member and leader include the ability to engender trust among the team participants. For the leader of the team, this may require the ability to demonstrate vulnerability, particularly in regard to the scope of one's knowledge or judgment. Most physicians find this very difficult as we are indirectly taught to project a mien of confidence, authority, and control. Was the physicians' responses to the 9 measures of satisfaction influenced by their overall comfort with the Guided Care model?

Highly functioning teams do not fear conflict or disagreement. Many physicians who do not have team membership or leadership skills might find this threatening. Thus, a team composed of a nurse, physician, specialist and other office staff who are responsible for caring for an elderly patient might silently disagree on how to manage a complex, chronic illness. Their silent disagreement could lead to passive aggressive behaviors or outright conflicting advice to the patient. Such a situation would certainly be reflected in a lower sense of satisfaction.

The Guided Care model of care requires strong team skills. While this article demonstrates positive effects on physician's satisfaction with certain aspects of care, it does not address how the model actually works to enhance the team skills of the physician. Other publications by this group have focused on the preparation of the Guided Care nurse which does include communication and leadership skill development.

It might be useful for this group to focus their continued development of the Guided Care model on enhancing those attitudes and behaviors of physicians that will make them highly functioning team members and leaders.

Competing interests:   None declared