Americans’ Contacts With Primary Care Physicians Did Not Increase After the Affordable Care Act
At the same time the Affordable Care Act increased the number of insured Americans, analysis of health care industry data shows a continued decline in contact with primary care physician services. The study applied an “ecology of medical care” framework analysis to a national dataset of Americans’ contact with the US medical care system. Tracked services included visits and calls to physicians, including primary care and sub-specialty physicians, emergency departments, inpatient hospitalizations, dental visits and home health visits. Analysis showed a drop in the uninsured rate post-Affordable Care Act, from 12.8% in 2013 to 7.6% in 2016. Between 2002 and 2016, patients were overall less likely to see a primary care physician, be hospitalized, or receive dental care. However, contact with home health visits increased. Despite the increase in insurance coverage, the Affordable Care Act appeared to have had minimal effect on the trend of decreasing primary care contact in the general population during the first two years after implementation.
The Ecology of Medical Care Before and After the Affordable Care Act: Trends From 2002-2016
Michael E. Johansen, MD, MS, et al.
Ohio Health, Grant Family Medicine, Columbus, Ohio
A National Decline in Primary Care Visits Associated With More Comprehensive Visits And Electronic Follow-Up
The number of primary care visits may be declining nationally, but analysis reveals that in-person visits have become more comprehensive and follow-up care has moved online. Researchers analyzed a weighted sample of 3.6 billion adult primary care visits from 2008 to 2015, collected through physicians surveyed by the National Ambulatory Medical Care Survey. They found primary care visits declined from 336 million to 299 million visits per year, representing a 20 percent decline over the study period. The decline in visits was most pronounced among adults 65 and older, white adults, and those in rural areas.
Simultaneously, primary care physicians provided more preventive services and procedures per visit, with more diagnoses addressed and medications prescribed. During the study period, the number of physicians who reported offering secure online messaging increased by 60%, with a 44% increase in the use of electronic medical records. The findings offer an optimistic interpretation that the decline in primary care visits per capita may be driven in part by two key improvements in primary care practice, namely, physicians conducting longer, more comprehensive visits and the increased use of non-face-to-face care to address issues outside of in-person visits.
National Trends in Primary Care Visit Use and Practice Capabilities, 2008–2015
Aarti Rao, et al.
Icahn School of Medicine at Mount Sinai, New York City, New York
Less is More, as National Statistics Show a Decline in Adult Primary Health Care Utilization
In an accompanying editorial to Rao et al and Johansen and Richardson, Donald E. Pathman, MD, MPH, professor at the University of North Carolina School of Medicine, provides a gestalt explanation of the decline in primary care visits among adults from the mid-2000s through 2016. Pathman reminds readers that the same decade that brought about the ACA also ushered in fundamental changes to how primary care is offered and organized. It saw many other changes in the American health care system: Outpatient services now target quality metrics facilitated by the electronic medical record. Care has become more team based, and EMRs make patient-team-physician communications easier between visits.
The two new studies present trends in global shifts in where people receive care and also in the services offered and content of the primary care visit. “Taken together,” Pathman concludes, “The findings of these two studies suggest that the falling rate of primary care physician visits for adults aged younger than 65 years is best explained by changes in the content and processes surrounding the primary care visit, and generally not due to care shifting to specialist physicians, emergency departments, and hospitals.”
Changes in Rates and Content of Primary Care Visits Within an Evolving Health Care System
Donald E. Pathman, MD, MPH
University of North Carolina, Department of Family Medicine, Chapel Hill, North Carolina
Does Blue Light Therapy Help Acne? Efficacy and Evidence Is Lacking
Conclusions about the effectiveness of blue light therapy for acne are limited. A new systematic review and meta-analysis of 14 randomized controlled trials of blue light therapy for acne shows methodological and reporting limitations—including small sample sizes, short intervention periods, and variation in reporting quality for acne outcomes. Only three of the trials reported significant improvements in expert-assessed acne severity with blue light therapy over a control group. The majority of trials do not provide sufficient evidence to conclude effectiveness. Acne is one of the most common reasons for clinical consultations. Market and patient demand is high for light therapy as an alternative to antibiotic approaches to acne treatment. Because evidence for blue light therapy is not conclusive, patients should discuss with their clinicians the possible benefits, costs, and alternatives for acne treatment. Blue light therapy may be beneficial for some patients, but more research is needed.
Blue-Light Therapy for Acne Vulgaris: A Systematic Review and Meta-Analysis
Anna Mae Scott, PhD, et al.
Bond University, Centre for Research in Evidence Based Practice, Gold Coast, Australia
Perspectives and Suggestions in Caring for High-Need, Complex Patients
High-need high-cost (HNHC) patients, many of whom are experiencing poverty, use a large portion of health care resources. Despite receiving more care, such patients often experience poor health outcomes. Teams providing intensive ambulatory care interventions were interviewed regarding how they view the work of serving socially and medically complex patient populations. Researchers conducted semi-structured, qualitative interviews with nine ambulatory care team members and six “usual care” team members, focused on multidisciplinary staff experiences. Interviews were performed at a Federally Qualified Health Center (FQHC) caring for predominantly homeless HNHC patients in the context of an ongoing implementation of an ambulatory intensive care unit intervention. The staff noted social, behavioral, and medical challenges leading to patient–health care system mismatch. Team members cared for HNHC patients by addressing both psychosocial and clinical needs together; staying connected to patients through chaotic periods; reinforcing commitment and cohesion among interdisciplinary team members; and being flexible enough to create individualized care, tailored to each patient’s situation. Participants more often defined success as improving patient engagement, as opposed to reducing utilization or cost.
Brian Chan, MD, MPH, et al.
Oregon Health and Science University, Division of General Internal Medicine and Geriatrics, Portland, Oregon
Capacity to Address Patient Social Needs Affects Primary Care Clinician Burnout
Twenty-nine primary care clinicians provided insight into the relationship between patient social needs and physician burnout through semi-structured interviews. Four key themes appeared throughout these interviews: (1) burnout can affect how clinicians evaluate their clinic’s social needs resources, (2) unmet social needs affect practices by influencing clinic flow, treatment planning, and clinician emotional wellness; (3) social services embedded in primary care clinics buffer against burnout by increasing efficiency, restoring clinicians’ medical roles, and improving morale; and (4) clinicians view clinic-level interventions to address patients’ social needs as a necessary but insufficient strategy to address burnout. The clinicians noted the importance of social needs interventions being timely, accessible, and tailored to each individual patient, while being responsive to patient feedback. The clinicians were skeptical that referral-based interventions based solely on referrals would adequately address patients’ social needs.
Capacity to Address Social Needs Affects Primary Care Clinician Burnout
Alina Kung, MD, MS, et al.
University of California, Berkeley - University of California, San Francisco Joint Medical Program, Berkeley, California
Associations Between Burnout and Practice Organization in Family Physicians
With the rate of burnout as high as 63% among family physicians, it is important to identify risk factors for physician burnout. The relationship between burnout and personal environmental and organizational risk factors was examined in a study of family physicians. A cross-sectional study of 1,437 physicians seeking to continue their American Board of Family Medicine Certification in 2017 was created using data from the examination registration process. Burnout was measured as a positive response to either of two validated questions measuring emotional exhaustion and depersonalization. The study revealed a burnout rate of 43.7%; 33.7% worked in hospital-owned practices with 65.5% had no ownership stake in their practice. Controlling for personal characteristics and practice organization, being in a hospital-owned practice and being a partial owner were positively associated with burnout. When also controlling for practice environment, no practice organization variable remained associated with burnout. The most important predictors of burnout were practice environment factors such as satisfaction with hours worked, control over workload, value alignment with department leaders, and sufficient time for documentation.
Associations Between Burnout and Practice Organization in Family Physicians
Lars E. Peterson, MD, PhD, et al.
American Board of Family Medicine, Lexington, Kentucky
Practice Organization Characteristics Related to Job Satisfaction Among General Practitioners in Eleven Countries
Organizational and functional features of general practitioner practices in 11 countries were studied in search of underlying reasons for job dissatisfaction. This was done by conducting a secondary analysis of 12,049 subjects in the 2015 Commonwealth Fund International Health Policy Survey of Primary Care Physicians. Job dissatisfaction was measured on a four-point Likert scale using the question: “How satisfied are you regarding your practicing of medicine?” The findings revealed dissatisfaction at work ranged from 8.1% in Norway to 37.4% in Germany. Greater dissatisfaction was noted among middle-aged (45–54 years old) GPs, those practicing in urban areas and those working alone. Also, high weekly workloads (greater than 50 hours), heavy administrative burdens, long delays in hospital discharge notices (greater than one month), and limited possibilities of offering same-day appointments added to the dissatisfaction. Using electronic health records and having an in-practice case manager were linked to higher satisfaction. Creating changes such as forming group practices, employing case managers, using electronic health records, and reducing workloads could reduce dissatisfaction levels.
Christine Cohidon, MD, PhD, et al.
University of Lausanne, Department of Family Medicine, Center for Primary Care and Public Health, Lausanne, Switzerland
Combating Physician Burnout and the Return to Medicine as a Calling
In this editorial, physician mental health researcher Katherine J. Gold, MD, MSW, MS, associate professor at the University of Michigan Medical School, synthesizes three studies to present an approach to addressing physician burnout that moves beyond meditation self-care sessions and pay raises to encompass the “calling” of medicine. The three studies investigate physician job satisfaction and factors in the work environment that bear influence on physician well-being and resilience. Practices with heavier workloads, longer hours, high burden of documentation, fewer home visits, and limited options for same-day appointments were linked to lower job satisfaction among physicians. Additionally, the inability to meet the complex and demanding social needs of vulnerable patients “creates a strong conflict between the internal calling of a physician and the reality of what can be offered to patients.” Gold argues that maintaining a sense of professional autonomy and work environments that align with a physician’s sense of professional “calling” are key factors to combat burnout. She concludes, “The solutions must recognize the importance of medicine as a calling and test interventions that promote consistency between the calling and its actual practice, that promote collegiality and teamwork, and that focus on building autonomy and control over the daily work lives of physicians.”
Combating Burnout: Back to Medicine as a Calling
Katherine J. Gold MD, MSW, MS
University of Michigan, Department of Family Medicine, Ann Arbor, Michigan
Program Linking Patients to Community Resources Shows No Significant Impact on Well-Being
A social prescribing initiative, designed to improve patients’ well-being and quality of life by connecting them to non-medical resources, did not prove effective overall. The study assessed the efficacy of a Scottish government-funded program that was developed to target social determinants of health among some of the most socioeconomically vulnerable adults in Glasgow. In the program, “Community-Links Practitioners” connected adult patients with community resources like exercise groups and drug and alcohol management support. The study evaluated the health-related quality of life, at baseline and after nine months, of 288 adults enrolled in the program. The authors compare their scores with 612 non-matched adults in comparison general practices and find no significant benefit in the intervention group. In a subgroup analysis, those who visited the practitioner three or more times showed improved quality of life, but many who enrolled did not fully utilize the program.The findings of this study call into question the effectiveness of such social prescribing programs for improving short-term health-related quality of life. Discovering ways to improve the uptake and engagement rates of the intervention may lead to better overall outcomes.
Effectiveness of Community-Links Practitioners in Areas of High Socioeconomic Deprivation
Stewart W. Mercer, MBChB, PhD, et al.
University of Edinburgh, Centre for Population Health Sciences, Usher Institute of Population Health Sciences and Informatics, Medical School, Edinburgh, Scotland
A Practical Approach to Recording Unstructured Field Observations in Primary Care Research
The authors present an overview of qualitative field observations, a research methodology that could be useful to enhance health research projects using primary data collection. The paper illustrates a practical approach to collecting and recording observational data through a “3 Cs” template of content, context, and concepts. To demonstrate how the method can be used routinely in practice, the authors provide an example of a completed template and discuss the analytical approach used during a study on informed consent for research participation in the primary care setting of Qatar. Fetters and Rubenstein write, “Field observations allow researchers to move beyond selected perceptions and protocols, and better understand what particular activities are like, who performs them, and the contexts in which they occur.”
Michael D. Fetters, MD, MPH, MA, et al.
University of Michigan, Department of Family Medicine, Ann Arbor, Michigan
Innovations in Primary Care
Innovations in Primary Care are brief one-page articles that describe novel innovations from health care’s front lines. In this issue:
Behind the Mask: Identity Formation and Team Building—A mask-making exercise helps medical school faculty and students connect their personal strengths to their professional identities in a care team environment.
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Annals of Family Medicine is a peer-reviewed, indexed research journal that provides a cross-disciplinary forum for new, evidence-based information affecting the primary care disciplines. Launched in May 2003, Annals is sponsored by seven family medical organizations, including the American Academy of Family Physicians, the American Board of Family Medicine, the Society of Teachers of Family Medicine, the Association of Departments of Family Medicine, the Association of Family Medicine Residency Directors, the North American Primary Care Research Group, and The College of Family Physicians of Canada. Annals is published six times each year and contains original research from the clinical, biomedical, social and health services areas, as well as contributions on methodology and theory, selected reviews, essays and editorials. Complete editorial content and interactive discussion groups for each published article can be accessed free of charge on the journal’s website, www.AnnFamMed.org.
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