Table of Contents
The Issue in Brief
Nov/Dec 2011
Impact of Insurance and Hospital Ownership on Hospital Length of Stay Among Patients With Ambulatory Care-Sensitive Conditions
Arch G. Mainous III, and colleagues
Background Research has suggested that for-profit US hospitals maximize financial margins from patient care by limiting therapies or decreasing length of stay for uninsured patients. This study examines whether lack of health insurance is related to length of stay and risk of mortality in for-profit and not-for-profit hospitals. The study examines hospitalizations for both Ambulatory Care-Sensitive Conditions (ACSCs, conditions in which hospitalizations may be avoidable with preventive care and early disease management in the outpatient setting) and non-ACSCs.
What This Study Found Patients without insurance have significantly shorter hospital stays, regardless of whether they are hospitalized for an ACSC or non-ACSC. Across all hospital types, the average length of stay for ACSCs was 2.77 days for uninsured individuals, 2.89 days for those with private insurance, and 3.19 days for those with Medicaid. Patients without insurance have a higher likelihood of death for non-ACSCs, but not for ACSCs.
Implications
- The authors call on clinicians to advocate for equal treatment of patients, regardless of insurance or payment status.
Effect of Closure of a Local Safety-Net Hospital on Primary Care Physicians' Perceptions of Their Role in Patient Care
Kara Odom Walker, and colleagues
Background In recent decades, large urban public hospitals, also known as safety-net hospitals, have closed in several major US cities. Previous research has shown that, following these closures, minority, elderly, and uninsured populations are at risk for poorer access and health outcomes. This study assesses the effects of a safety-net hospital closure on local primary care doctors.
What This Study Found The hospital closure had some effect on 67% of primary care doctors and their practices, including (1) reduced local access to specialist consultations, direct hospital admissions, and timely emergency room evaluation; (2) more patient delays in care and worse health outcomes resulting from poor patient understanding of the health care system changes; and (3) loss of colleagues and opportunities to teach residents and medical students. The impact of the closure was felt by doctors more than 20 miles away from the hospital.
Implications
- It is important to anticipate and address the challenges raised in this study, particularly as safety-net hospitals and primary care practices work to create effective medical homes to improve quality of care for underserved and uninsured populations.
- The authors suggest that primary care physicians be informed and consulted when a major disruption to the health care delivery system is planned.
Parent and Child Usual Source of Care and Children's Receipt of Health Care Services
Jennifer E. DeVoe, and colleagues
Background Children with a usual source of health care (USC) have better access to care, which may contribute to better health. This study examines whether children's access to health care services is associated with their parents' USC status.
What This Study Found In this study, more than 18% of children have no parent in the household with a USC. Children who have a USC, but whose parents do not, are more likely to have unmet medical needs, including an insurance coverage gap, an unmet medical or prescription need, and no yearly dental visits.
Implications
- The authors call for policy changes to improve access to a usual source of care for all family members.
- The authors suggest that clinicians develop practice-based interventions to assist parents and children in finding stable usual sources of care.
Trends in Quality During Medical Home Transformation
Leif I. Solberg, and colleagues
Background Many primary care practices are striving to transform themselves into patient-centered medical homes (PCMHs). How does the transformation to a PCMH affect quality of care? This study looks at changes in technical quality and patient experience as primary care clinics transform themselves into patient-centered medical homes.
What This Study Found Transformation to a PCMH is associated with improvements in quality and patient satisfaction, but the rate of improvement is slow. In this study, practices had a 1% to 3% per year increase in patient satisfaction and a 1% to 4% per year increase in performance on quality measures for diabetes, coronary artery disease, preventive services, and generic medication use. When compared with other medical groups in the region, the rates of increase were greater for satisfaction, but similar for the quality measures.
Implications
- In the transformation to a PCMH, expectations for large and rapid improvements in health or patient experience are probably unrealistic.
Complaints Against Family Physicians Submitted to Disciplinary Tribunals in the Netherlands: Lessons for Patient Safety
Sander Gaal, and colleagues
Background It is important to identify and learn from patient safety incidents in primary care. One approach may be to examine complaints against family physicians submitted to Dutch disciplinary tribunals, which offer patients the opportunity to file complaints against doctors outside a legal malpractice system and without possible financial compensation. This study analyzes 250 such complaints submitted between 2008 and 2010.
What This Study Found Complaints covered a wide range of topics, with wrong diagnosis (44%) and insufficient medical care (23%) most prevalent. In 74 cases, a serious health outcome occurred; 37 of these were assessed by disciplinary tribunals as avoidable harms.
Implications
- Analysis of disciplinary verdicts may be an appropriate method to identify and analyze incidents with serious health outcomes. Their representativeness, however, is unknown.
- In this study, most incidents with serious health consequences were diagnosis related. Although risks cannot be completely avoided, the authors suggest that patient safety programs in primary care increase their focus on diagnostic procedures.
Translating Cholesterol Guidelines Into Primary Care Practice: A Multimodal Cluster Randomized Trial
Charles B. Eaton, and colleagues
Background Underscreening and undertreatment of dyslipidemia (abnormal levels of cholesterol and/or other fat in the blood) are widespread problems. This study examines whether activating patients, by use of a computer program about the patient's risk of heart attack, and providing the primary care team with a PDA-based decision support tool result in better adherence to cholesterol guidelines and achievement of cholesterol goals.
What This Study Found This study showed no benefit to activating patients and supporting the health care team in cholesterol management. Another form of analysis, however, suggests potential benefit to this multifaceted approach.
Implications
- The authors call for further research on the use of both behavioral science and informatics to empower patients and support clinicians.
Patient-Doctor Depth-of-Relationship Scale: Development and Validation
Matthew J. Ridd, and colleagues
Background The ongoing relationship, or continuity, between doctor and patient is a key element of family medicine/general practice. Tools to measure the impact of continuity have tended to look at duration, rather than depth, of the relationship. This report presents a new patient self-completion instrument designed to measure the depth of the patient-doctor relationship.
What This Study Found The Patient-Doctor Depth-of-Relationship Scale can be used to evaluate the value of personal continuity. It has an eight-item scale with good internal reliability. Application of the scale finds an association between seeing the same doctor and a deep patient-doctor relationship, although the relationship appears to be nonlinear.
Implications
- Future research is needed to further establish the validity of the scale and examine a possible association between patient-doctor depth of relationship and improved patient care.
Promoting Healthy Lifestyles and Decreasing Childhood Obesity: Increasing Physician Effectiveness Through Advocacy
Jessica Schorr Saxe
Background Childhood obesity rates have more than tripled since 1980, with almost one-third of children aged 2 to 18 years now overweight or obese. Although clinical guidelines exist for screening and counseling children, this public health crisis resides in the community. Physicians can engage with the community by advocating locally and at state and federal levels to effect environmental and policy change.
Family Physicians Leaving Their Clinic—The Balint Group as an Opportunity to Say Good-bye
Yuval Shorer, and colleagues
Background The case of a grieving family helps a physician recognize her own grief over a forthcoming move from her practice. With the help of her Balint group, the physician becomes aware of the need to plan her departure and reflect on the meaning and implications of leaving for staff and patients.