Table of Contents
The Issue in Brief
Extended Office Hours and Health Care Expenditures: A National Study
Anthony Jerant , and colleagues
Background Timely access to care could allow earlier diagnosis and treatment of health conditions and reduce health care expenditures. This study examines the relationship between access to extended (evening and weekend) office hours and health care utilization, outcomes, and expenditures, as well as mortality.
What This Study Found Patients who have access to a regular source of health care that offers evening and weekend hours have significantly lower health expenditures than those who do not. In this study, total expenditures were 10 percent lower among patients reporting access to extended hours compared to those lacking such access, an association related to lower prescription drug and expenditures related to office visits (such as testing). The reduced expenditures do not have apparent adverse effects on mortality.
Implications
- Extended office hours may be associated with relatively judicious use of primary health care resources, including more generic medication prescribing and less discretionary testing.
Thomas Bodenheimer , and colleagues
Background The average US primary care physician's panel size (number of patients) is 2,300 and is expected to increase. Under a traditional model of practice, that number is too large for delivering consistently high-quality of care. This study estimates panel sizes that might be reasonable if some primary care services are delegated to nonphysician team members.
What This Study Found If some preventive and chronic care services are delegated to nonphysician team members, primary care practices can provide recommended care with panel sizes that can be achieved using the available primary care workforce. Based on 3 assumptions about the degree of task delegation, a primary care team could care for a panel of 1,947, 1,523, or 1,397 patients.
Implications
- Replacement of physician-only care with team-based care will require a significant change in the culture and structure of primary care practice.
- High-functioning primary care teams have the potential to ensure access and quality for the nation's population and provide a reasonable work life for physicians and other team members.
Influence of Primary Care on Breast Cancer Outcomes Among Medicare Beneficiaries
Richard G. Roetzheim , and colleagues
Background Despite the important role played by primary care physicians in preventive care, the actual effect of primary care on cancer outcomes has not been well studied. This study looks at the relationship between primary medical care and breast cancer outcomes in Medicare beneficiaries.
What This Study Found Medicare beneficiaries with breast cancer who make more visits to primary care physicians in the 2 years before their diagnosis have better breast cancer outcomes, including greater use of mammography, reduced odds of late-stage diagnosis, and lower overall and breast cancer mortality. Among 105,000 female Medicare beneficiaries with breast cancer, those with 10 or more office visits are 50 percent less likely to have late-stage cancer diagnosed. They have 41 percent lower breast cancer mortality and 27 percent lower overall mortality, compared with women having 1 or no visit.
Implications
- Improved outcomes are partly explained by greater use of mammography and resultant earlier stage diagnosis.
- Access to primary medical care may be an important factor in achieving optimal outcomes for breast cancer patients.
Muriel Jean-Jacques , and colleagues
Background Nearly one-half of eligible adults are not up to date on colorectal cancer screening. This is particularly a problem among racial and ethnic minorities. This study examines the effectiveness of mailing fecal occult blood test (FOBT) kits to community health center patients who are overdue for colorectal cancer screening.
What This Study Found Direct mailing of fecal occult blood test kits to patients eligible for colorectal cancer screening appears to improve screening in historically underserved communities. Patients who receive FOBT kits in the mail with follow-up telephone calls to initial nonresponders have a 30 percent screening rate, compared with a 5 percent screening rate among patients in the usual care group.
Implications
- Prior studies have shown that direct-to-patient mailing of FOBT kits can lead to higher colorectal cancer screening rates in predominantly white, middle-class or well-insured populations. This study demonstrates that the strategy can significantly improve screening rates among economically disadvantaged patients from a wide range of racial, ethnic, and cultural backgrounds.
Adult Cancer Survivors Discuss Follow-up in Primary Care: 'Not What I Want, But Maybe What I Need'
Shawna V. Hudson , and colleagues
Background Primary care clinicians have an important role in follow-up care for cancer survivors. This study explores patient preferences about the role of primary care physicians in extended cancer follow-up care.
What This Study Found Many cancer survivors have concerns about seeing their primary care physician for cancer-related follow-up care and prefer receiving follow-up care from their cancer specialists. They describe the following barriers to follow-up care from their primary care physician: (1) lack of cancer expertise, (2) limited or no involvement with original cancer care, and (3) lack of care continuity. In this study, one-third of participants believe there is a role for primary care clinicians in cancer follow-up care, including: (1) performing routine preventive screening tests, (2) supplementing cancer-related specialist care, and (3) providing follow-up medical care when "enough time had passed" or the survivors feel they can reintegrate into the non-cancer population.
Implications
- The authors call for primary care to engage meaningfully in the case management of adult cancer survivors.
- The authors also suggest that specialists educate and discharge their patients with a better understanding of what cancer follow-up care is, its lifelong duration, and the potential for varying degrees of monitoring, as well as the role of the primary care physician.
Health Care Consumers' Preferences Around Health Information Exchange
Rina V. Dhopeshwarkar , and colleagues
Background Health information exchange (HIE), the exchange of electronic health information across health care clinicians and organizations, could help improve quality of health care. Little is known, however, about features, safeguards, and policies that would help consumers feel more comfortable about the privacy and security of their electronic health information. This survey of 170 New Yorkers about the use of electronic health records (EHRs) and HIE aims to understand their detailed preferences for the privacy and security of their health information.
What This Study Found In New York, where patients must actively consent to having their data accessed through health information exchange, survey respondents are generally supportive of electronic sharing of health information and are willing to have their health information automatically stored in an HIE; however, they want to have control over the privacy and security of that information. More than two-thirds of people surveyed are willing to have their health information automatically stored in an HIE. Most respondents, however, want safeguards against unauthorized viewing of their information. They also want to be able to see who has viewed their information, be able to stop electronic storage of their data, be able to stop all viewing, and be able to select which parts of their health information are shared. Among the approximately one-third of patients who are uncomfortable with automatic inclusion of their health information in an electronic database for HIE, 78 percent wish to approve all information explicitly, and most prefer restricting information by clinician, visit, or information type.
Implications
- The authors conclude that, given the highly sensitive nature of health information and the consequences that can occur in the event of its disclosure, patient preferences around the storing and sharing of electronic health information should be considered when developing and implementing systems, standards and policies. They advocate for consent policies that allow consumers to control what, by whom, and for how long their health information can be accessed.
Trajectories of Psychological Distress After Stroke
Jennifer H. White , and colleagues
Background Most stroke survivors receive ongoing care in the community after discharge from a secondary or tertiary health care setting. This study explores common disease paths or patterns of psychological distress and recovery in the 12 months after a stroke.
What This Study Found Based on interviews with 23 recent stroke victims, researchers identify 4 distinct trajectories�resilience, ongoing mood disturbance, emergent mood disturbance, and recovery from mood disturbance. Recovery from mood disturbance is facilitated by gains in independence and self-esteem and by having an internal health locus of control.
Implications
- Identifying distinct trajectories of psychological morbidity may help primary care physicians develop appropriately timed methods for promoting better mental health among stroke patients.
Validation of a Generic Measure of Continuity of Care: When Patients Encounter Several Clinicians
Jeannie L. Haggerty , and colleagues
Background Patients often see multiple clinicians, so it is important to be able to assess whether there is continuity or fragmentation in their health care. This study develops and validates a tool to measure management of health problems over time from the patient perspective.
What This Study Found This new measure reliably captures nine dimensions of continuity experienced by patients when they encounter multiple caregivers in different places. The instrument includes a measure of team continuity, recognizing that patients can and do establish relational continuity with more than one clinician. The measure advances previous work by integrating different types of continuity.
Implications
- The ultimate test of this tool, the authors suggest, will be to show whether improving continuity translates into better quality of care and health outcomes.
Linda M. Hunt , and colleagues
Background This study of management of type 2 diabetes and hypertension examines clinicians' treatment strategies, factors influencing treatment decisions, and patient understandings and experiences in managing these illnesses.
What This Study Found With 11 percent of the US population and 40 percent of people older than 60 years taking 5 or more medications, this study examines the underlying influence and unintended outcomes of the dramatic rise in polypharmacy in patients with diabetes, hypertension, or both. The authors suggest that heavy use of pharmaceuticals is caused by a number of factors, most notably (1) increasingly stringent diagnostic and treatment thresholds for common chronic conditions, (2) clinician auditing and reward systems, and (3) a prescribing cascade whereby more medications are prescribed to control the effects of already prescribed medications. The authors identify several challenges to patient well-being resulting from a heavy reliance on pharmaceuticals, including financial costs and adverse drug effects. They present a conceptual model, the inverse benefit law, to provide insight into the impact of pharmaceutical marketing efforts on the observed trends.
Implications
- The authors call for (1) policies that will exclude individuals or organizations with financial conflicts of interest from involvement with guideline-writing panels, (2) physicians to be discouraged from seeing drug representatives, and (3) the monitoring of pay-for-performance plans for evidence of unintended negative effects on patients.
Stephen J. Gillam , and colleagues
Background The UK Quality and Outcomes Framework (QOF) is arguably the most comprehensive national primary care pay-for-performance program in the world. It is a complex program of financial incentives and information technology to promote structured and team-based care with the aim of improving quality of care. This study analyzes existing research to determine the impact of the QOF on the quality of primary medical care in the United Kingdom.
What This Study Found There have been modest improvements in quality of care since the QOF was introduced in 2004. The QOF improved quality of care for incentivized conditions during its first year of implementation, and returned to preintervention rates of improvement in the following years. There have been some modest cost-effective reductions in mortality and hospital admissions, and narrowing of differences in performance in deprived areas compared with nondeprived areas. Some doctors report improved data recording and teamwork, and nurses report enhanced specialist skills. Both groups, however, believe that patient-centeredness of consultations and continuity are negatively affected by QOF. Little is known of what patients think of the changes, although anecdotal reports suggest that unintended consequences may be detracting from patient-centered care.
Implications
- In view of the findings, the authors recommend policy makers continue to be cautious about implementing similar programs, and they call for future research into how to improve quality across different domains while minimizing costs and unintended adverse effects.