Index by author

The Issue in Brief

Mar/Apr 2012

Lung Cancer Screening Practices of Primary Care Physicians: Results From a National Survey

Carrie N. Klabunde, and colleagues

Background Major expert groups do not recommend screening people without symptoms for lung cancer, including people with heavy or long-term smoking histories, because of a lack of strong evidence. This study examines US primary care physicians' self-reported lung cancer screening practices.

What This Study Found Primary care physicians in the United States frequently order lung cancer screening tests for asymptomatic patients. In a nationally representative survey of 962 primary care physicians, which used clinical vignettes to assess screening practices, 57 percent of respondents ordered at least one of three lung cancer screening tests (chest radiograph, low-radiation does spiral computed tomography, or sputum cytology) in the past 12 months for patients without symptoms. Thirty-eight percent reported ordering no tests. Physicians were more likely to order screening tests if they believed expert groups recommend lung cancer screening or that screening tests are effective; if they graduated from medical school 20 to 29 years ago; if they would recommend screening for asymptomatic patients, including patients without substantial smoking exposure; and if their patients had asked them about screening.

Implications

• To avoid inappropriate ordering, primary care physicians need more information about lung cancer screening's evidence base, guidelines, potential harms, and costs.

How the Medical Culture Contributes to Coworker- Perpetrated Harassment and Abuse of Family Physicians

Baukje Miedema, and colleagues

Background Physicians experience many forms of harassment and abuse, including verbal abuse, intimidation, sexual harassment, stalking, and assault, from patients and colleagues. This study aims to to document the prevalence, rates, and impact of abuse in the workplace of family physicians in Canada.

What This Study Found The current medical culture appears to contribute to harassment and abuse in the workplace of family physicians in Canada. Based on interviews with 23 female and 14 male practicing family physicians in Canada, the study finds four ways in which the medical culture intentionally or unintentionally contributes to the facilitation and perpetuation of abuse in the workplace of family physicians: (1) modeling of abusive behaviors, (2) status hierarchy within the medical community, (3) shortage of physicians, and (4) lack of transparent policies and follow-up procedures after abusive encounters. The authors discuss these findings using the criminology-based broken window theory, which asserts when lesser criminal acts, such as broken windows, are tolerated, more vandalism and other types of crime will eventually occur in the community.

Implications

• Effective elimination of abuse must start from efforts that begin on the first day of medical school and continue through residency training and into clinical practices.

Video Elicitation Interviews: A Qualitative Research Method for Investigating Physician-Patient Interactions

Stephen G. Henry, and colleagues

Background Face-to-face interactions between doctors and patients are central to primary care and an important focus of primary care research. Video elicitation interviews are a technique for evaluating these interactions. This article describes the concept and method of video elicitation interviews and provides practical guidance for its use.

What This Study Found During video elicitation interviews, researchers interview patients or physicians about a recent clinical interaction using a video recording of that interaction as an elicitation tool. Video elicitation allows researchers to integrate data about the content of physician-patient interactions, gained from video recordings, with data about participants' associated thoughts, beliefs, and emotions, gained from elicitation interviews. This method also facilitates investigation of specific events or moments during interactions.

Implications

• While video elicitation interviews are logistically demanding and require considerable time and resources, the detailed data they produce make the effort worthwhile for many important research questions in primary care.

Association of Patient-Centered Outcomes With Patient- Reported and ICD-9-Based Morbidity Measures

Elizabeth A. Bayliss, and colleagues

Background Evaluating patient-centered care for complex patients requires the ability to approriately measure morbidity (illness) for a variety of clinical outcomes. This study compares the contributions of self-reported morbidity and morbidity measured using administrative diagnosis data for both patient-reported outcomes and utilization outcomes.

What This Study Found A comprehensive assessment of a patient's morbidity requires both subjective and objective measurement of diseases and disease burden, as well as an assessment of emotional symptoms. Comparing two different approaches to gauging morbidity - (1) objective measurement using ICD-9 diagnosis codes and (2) subjective measurement using patient-reported disease burden and emotional symptoms - researchers conclude both are needed. In data on 961 older adults with three or more medical conditions, morbidity measured by diagnosis code is more strongly associated with higher utilization, whereas self-reported disease burden and emotional symptoms are more strongly associated with patient-reported outcomes.

Implications

• Accurate measurement strategies to account for morbidity burden will become increasingly important in developing new methods for evaluating patient-centered care delivery for complex patients.

Measures of Multimorbidity and Morbidity Burden for Use in Primary Care and Community Settings: A Systematic Review and Guide

Chris Salisbury, and colleagues

Background Many primary care patients have multiple medical conditions (multimorbidity). To assess the impact of multimorbidity, it is necessary to measure it. This analysis of existing research identifies measures of multimorbidity and morbidity (illness) burden suitable for use in research in primary care and community populations and investigates their validity.

What This Study Found This systematic review identifies 17 different measures. The measures most commonly used in primary care, and for which there is greatest evidence of validity, are disease counts, the Charlson index, and the Adjusted Clinical Groups (ACG) System. Different measures are most appropriate according to the outcome being studied and the type of data available. For example, researchers interested in the relationship between multimorbidity and health care utilization will find most evidence for the validity of the Charlson Index, the ACG System and disease counts, but evidence is strongest for the ACG System in relation to costs, for Charlson index in relation to mortality, and for disease counts or Charlson index in relation to quality of life. Other measures, such as the Cumulative Index Illness Rating Scale and Duke Severity of Illness Checklist, are more complex to administer and their advantages over easier methods have not been well established.

Implications

• Research is needed to directly compare the performance of different measures.

A Systematic Review of Prevalence Studies on Multimorbidity: Toward a More Uniform Methodology

Martin Fortin, and colleagues

Background This systematic review identifies and compares studies reporting the prevalence of multimorbidity (multiple medical conditions) in patients and suggests methodological aspects to be considered in the conduct of such studies.

What This Study Found In studies looking at the prevalence of multimorbidity, there is a great deal of variation in both methods and findings. The largest differences in prevalence, in both primary care and the general population, are seen at the age of 75 years. In addition to differing geographic settings, the studies differ in recruitment method and sample size, data collection, and operational definitions of multimorbidity, including the number of conditions and the conditions selected. All of these differences affect prevalence estimates.

Implications

• Use of more uniform methodology should permit more accurate estimation of the prevalence of multimorbidity and facilitate comparisons across settings and populations.
• Investigators designing future studies should consider the number of diagnoses to be assessed (with 12 or more frequent diagnoses of chronic diseases appearing ideal) and should attempt to report results for differing definitions of multimorbidity (both 3 or more diseases and the classic 2 or more diseases).

New Pathways for Primary Care: An Update on Primary Care Programs From the Innovation Center at CMS

Richard J. Baron

Background The Center for Medicare and Medicaid Innovation (Innovation Center) was created by the 2010 Patient Protection and Affordable Care Act to test new models of health care delivery to improve the quality of care while lowering costs. This report highlights some of the Center's new primary care programs and initiatives.

What This Study Found The Innovation Center is testing new payment and service delivery models, relying on collaboration among multiple stakeholders in the interest of better, more affordable patient care. Specific initiatives include a Multi-Payer Advanced Primary Care demonstration, a Federally Qualified Health Center demonstration, and a Comprehensive Primary Care initiative testing whether larger, strategic investment in primary care will lead to improved health at lower overall costs.

Implications

• By changing delivery models and moving to a payment model that rewards physicians for quality of care instead of volume of care, the United States may be able to achieve the kind of health care patients want to receive and primary care physicians want to provide.

Who Will Have Health Insurance in the Future? An Updated Projection

Richard A. Young, and colleagues

Background Previous estimates found that the cost of a family health insurance premium would equal the median household income by the year 2025. The current study updates this estimate based on the 2010 Patient Protection and Affordable Care Act that is reforming health care payment in the United States.

What This Study Found The cost of an average family insurance premium is estimated to surpass household income by the year 2033. Analyzing data from the Medical Expenditure Panel Survey and the US Census Bureau, researchers developed an updated model of insurance premium cost and household income projections. If health insurance premiums and national wages continue to grow at recent rates, and if the US health system makes no major structural changes, the average cost of a family health insurance premium will equal 50 percent of the household income by the year 2021 and surpass it by 2033. If out-of-pocket costs are added to premium costs, the 50 percent threshold is crossed by 2018 and exceeds household income by 2030.

Implications

• Although the change in the projection might be perceived as progress, in part owing to a recent slowdown in the rate of increases in health insurance premiums, employee contributions to insurance premiums and out-of- pocket expenses have grown faster than overall premium costs, suggesting that insurers are shifting costs to patients in other ways. The authors assert the slowdown in the rate of premium increases has been offset by higher deductibles and co-payments and fewer covered services.
• Continuing to make incremental changes in US health policy will likely not bend the cost curve, which has eluded policy makers for the past 50 years. Unless major changes are made to the US health care system, private insurance will become increasingly unaffordable for low to middle-income Americans.

The Next Phase of Title VII Funding for Training Primary Care Physicians for America's Health Care Needs

Robert L. Phillips, Jr, and colleagues

Background Health reform will add millions of Americans to the ranks of the insured; however, their access to health care is threatened by a deep decline in the production of primary care physicians. Poorer access to primary care risks poorer health outcomes and higher costs. Meeting this increased demand requires a major investment in primary care training, but Title VII, section 747 of the Public Health Service Act, which is intended to increase the quality, quantity, and diversity of the primary care workforce, has been severely cut during the past two decades. This article describes the shrinking production of primary care physicians and its adverse consequences for the health of the US population.

What This Study Found To revitalize the national primary care workforce and ensure access to care after the passage of the 2010 Patient Protection and Affordable Care Act, policy makers should increase funding for Title VII. New and expanded Title VII initiatives are required to increase the production of primary care physicians; establish high-functioning academic, community-based training practices; increase the supply of well-trained primary care faculty; foster innovation and rigorous evaluation of these programs; and ultimately to improve the responsiveness of teaching hospitals to community needs. Failure to launch a national primary care workforce revitalization program would put the health and economic viability of the United States at risk.

Implications

• The authors call on the US Congress to increase funding for Title VII, Section 747 roughly 14-fold to $560 million annually - a small investment in light of the billions that Medicare currently spends to support graduate medical education.

The Myth of the Lone Physician: Toward a Collaborative Alternative

George W. Saba, and colleagues

Background In the United States, the traditional image of the primary care doctor is that of the lone physician, black bag in hand. Although the reality of day-to-day life for primary care physicians is far from this idyllic image, the lone physician has gained mythic status.

What This Study Found This essay proposes a new physician paradigm that acknowledges the current realities of primary care practice. A more collaborative alternative places the primary care physician in the context of a highly functioning health care team. It brings together the patient network and care team network, and fulfills the collaborative, interprofessional, patient-centered needs of new models of care. For high-functioning health care teams to develop and thrive, the administrative leadership of a clinical practice must view this paradigm shift as essential to providing optimal care.

Implications

• A new collaborative physician paradigm may help to ensure that the work of primary care physicians remains compassionate, gratifying, and meaningful.