Table of Contents
The Issue in Brief
Cost Estimates for Operating a Primary Care Practice Facilitation Program
Steven D. Culler , and colleagues
Background Practice facilitation is a promising and practical method for supporting practice redesign, but little is known about its cost. This article reports on costs of providing practice facilitation to small primary care practices.
What This Study Found Practice facilitation using outside consultants is estimated to cost a small primary care practice between $9,670 and $15,098 per year, or the cost of two to three hospitalizations. The median direct cost of practice facilitation focused on improving chronic illness care, including 6 meetings over a 12 month period, is $9,670 per practice (range = $8,050 to $15,682). These estimates do not include overhead costs to the practice for staff and systems.
Implications
- Because much of the cost of practice facilitation is devoted to start-up and practice assessment, the costs of ongoing facilitation activities in subsequent years would likely be much lower than estimated above.
Katrina E. Donahue , and colleagues
Background Practice transformation is the cornerstone of the future of family medicine and health care reform, but little is known about how the process occurs. This study set out to develop and test a model of the natural history of practice transformation among 18 primary care practices in North Carolina during a 2-year period.
What This Study Found This study identifies three trajectories of transformation that practices can follow-transformed, activated and engaged-as well as factors affecting practices' engagement in change efforts, the rate of quality improvement, and sustainability. According to the model, transformed practices experience robust, broad-based improvement, have highly engaged leadership, and use data to drive decisions. Activated practices experience moderate change on a slower improvement trajectory, usually encountering one or more barriers that take time to overcome. Engaged practices do not improve or are unable to sustain change because of multiple competing distractions that interfere with practice transformation.
Implications
- Internal and external practice motivations (eg, improved reimbursement, office efficiencies, better patient outcomes, institutional leadership, pay-for-performance programs, and clinician comparisons) and specific supports (eg, IT support, practice facilitators, continuing medical education, and learning sessions) affect engagement, rate of quality improvement, and long-term sustainability of transformation efforts.
- Early successes play a key role as practices learn how to change their performance.
- Practice transformation is a medium- to long-term process that varies by practice capacity, leadership, community context, and support.
Eric K. Shaw , and colleagues
Background This study evaluates a practice-based quality improvement intervention. Practices were given a specific goal (to improve colorectal cancer screening rates) and a change process (a series of facilitated team meetings and learning collaboratives), and were allowed to generate their own quality improvement objectives and strategies in hopes of enhancing their capacity for change.
What This Study Found Among 23 primary care practices, there was no significant improvement in screening rates in intervention practices compared with control practices. Successful implementation of the quality improvement program did not always translate into improved screening rates. There were associations between how well practice leaders fostered team development and the extent to which team members felt safe to engage in the change process. High-performing practices appeared to improve their capacity for change more than low-performing practices through the use of a reflective adaptive process.
Implications
- Practice transformation cannot be realized through only a series of incremental quality improvement projects. Developing greater organizational learning and change capacities is required.
- The quality improvement approach used in this study (Multimethod Assessment Process, Reflective Adaptive Process, facilitated team meetings, and learning collaboratives) may not be an optimal strategy for single-target interventions, particularly if gains in short-term guidelines are the goal.
- The researchers call for future research to address not only whether quality improvement interventions work but also why they work.
Dextrose Prolotherapy for Knee Osteoarthritis: A Randomized Controlled Trial
David Rabago , and colleagues
Background Knee osteoarthritis is a common, debilitating, chronic disease. This study tests the effectiveness of prolotherapy-an injection using a sugar solution to relieve musculoskeletal pain-for knee osteoarthritis.
What This Study Found Dextrose prolotherapy offers sustained improvement of pain, function, and stiffness for patients with knee osteoarthritis. Ninety adults with at least 3 months of painful knee osteoarthritis received dextrose prolotherapy injections, saline injections, or at-home exercise. Injections were done at 1, 5, and 9 weeks with as-needed additional treatments at weeks 13 and 17. Patients receiving dextrose prolotherapy improved more at 52 weeks and reported significantly better function than patients receiving saline and exercise. Individual knee pain scores also improved more in the prolotherapy group. Patient satisfaction with prolotherapy was high and no adverse events were reported.
Implications
- With most of the population showing evidence of osteoarthritis by the age of 65 years, the authors call for larger studies to compare the effectiveness of prolotherapy for knee osteoarthritis with other therapies.
Prognosis of Abdominal Pain in Children in Primary Care-A Prospective Cohort Study
Yvonne Lisman-van Leeuwen , and colleagues
Background Chronic abdominal pain (pain at least once a month during at least 3 consecutive months, with an impact on daily activities) has major implications for a child's well-being and use of the health care system. This study describes the prognosis for children with abdominal pain in primary care.
What This Study Found Chronic abdominal pain is highly prevalent and long lasting among children seen in primary care. In children ages 4 to 17 years with abdominal pain, most had or developed chronic abdominal pain. Chronic abdominal pain was present in 47 percent of children at the initial visit, and 79 percent at one or more follow-up points (3, 6, 9, and 12 months). The median duration of abdominal pain was 8.3 months, with children aged 10 to 17 years having the longest duration (median = 9 months). Girls had chronic abdominal pain more frequently during follow-up and with longer duration than boys.
Implications
- Given this poor prognosis, the authors call for follow-up of children with chronic abdominal pain.
Wayne J. Katon , and colleagues
Background Psychosocial and clinical factors can be associated with hypoglycemia (low blood glucose levels) in patients with diabetes, but there has been little research into the relationship between depression and severe hypoglycemic episodes. This study examines that association.
What This Study Found Patients with diabetes and major depression are at increased risk of severe hypoglycemic episodes requiring hospitalization or a visit to the emergency room. Over a 5-year period, depressed adult patients with diabetes had a significantly higher risk of a severe hypoglycemic episode and a greater number of hypoglycemic episodes compared with nondepressed patients.
Implications
- The increased risk of severe hypoglycemic episodes in patients with depression may be due to poor self-care or psychobiologic changes associated with depression.
- The authors call for research to assess whether recognition and effective treatment of depression among diabetic patients prevents severe hypoglycemic episodes, as well as increased risk of complications and mortality.
Amy L. Ahern , and colleagues
Background Previous international research found that a commercial Weight Watchers program was more successful in helping people lose weight than a standard primary care-based intervention. In this study, researchers analyze the accounts of a small sample of 16 participants' experiences with these two programs.
What This Study Found Referral to a commercial weight loss provider resonates with participants' general explanatory model of being overweight; they want support and motivation rather than education in a medical context, and they value the ease of access and frequent contact the commercial provider offers. Many report a resistance to the medicalization of being overweight. Some patients prefer individual-level support through their physician, and, in this study, all were positive about the opportunity to access support through the primary care setting.
Implications
- The authors conclude these findings support providing patients with a range of options for weight management in primary care, including commercial programs and other interventions outside the traditional medical setting, to find what best suits their needs and lifestyle.
Publication of Research Presented at STFM and NAPCRG Conferences
Robert E. Post , and colleagues
Background Presentations of original research are a key strategy in disseminating new knowledge in academic medicine. To help the knowledge base move forward, it is important that presentations of original research be published in peer-reviewed journals. This study evaluates the proportion of presentations at recent primary care research conferences that have become publications.
What This Study Found More than one-third of all original research presentations from the meetings of the North American Primary Care Research Group and Society of Teachers of Family Medicine eventually become publications, according to an analysis of 1,329 oral and poster presentations from the 2007 and 2008 annual conferences. A mean time of about 15 months from presentation to publication for family medicine is comparable to that of other fields. Less than two out of every five publications were in a family medicine journal, indicating breadth in family medicine research.
Implications
- That two-thirds of research presentations at major academic family medicine meetings appear not to transition to peer-reviewed publications, the authors assert, suggests room for improvement in developing and disseminating scholarship.
- Barriers to the discipline's promotion of research development include lack of faculty protected time, lack of mentorship, and lack of specific funding for family medicine research.
Experienced Continuity of Care When Patients See Multiple Clinicians: A Qualitative Metasummary
Jeannie L. Haggerty , and colleagues
Background Tools are needed to measure continuity of care (consistent and coherent care management) between different clinicians. In this study, researchers identify continuity-related themes through a meta-summary of previous qualitative research on patients' experience of care from multiple clinnicians.
What This Study Found Patients experience continuity of care as security and confidence rather than as seamlessness. Patients' desire for connectedness extends beyond health care encounters to include connection between health care and the rest of the patient's life, which translates to a sense of security and confidence.
Implications
- Although most continuity-related reforms emphasize integration of information and services, this study underlines the need to support and protect relational continuity with trusted and trustworthy clinicians who act as partners in care.
In Search of Joy in Practice: A Report of 23 High-Functioning Primary Care Practices
Christine A. Sinsky , and colleagues
Background As American physicians spend more time on large volumes of clerical work that does not utilize their training, they face burnout, which in turn threatens patient care. In this study, researchers gather innovations they believe can facilitate joy in practice and reduce physician burnout.
What This Study Found A shift from a physician-centric model of work distribution and responsibility to a shared-care model with higher levels of clinical support per physician and frequent forums for communication can result in high-functioning teams, improved professional satisfaction, and, potentially, greater joy in practice. Site visits to 23 high-performing family practices revealed 5 key innovations: (1) proactive planned care, with previsit planning and previsit laboratory tests; (2) shared clinical care among a team with expanded protocols, standing orders, and panel management; (3) shared clerical tasks with collaborative documentation, nonphysician order entry, and streamlined prescription management; (4) improved communication by verbal messaging and in-box management; and (5) improved team functioning through co-location, team meetings, and work flow mapping.
Implications
- These innovations, the authors assert, can address barriers to the healing relationship between physician and patient, take advantage of the resources of the health care team, and improve care for patients, thereby enhancing physician joy in practice.
Organizational Leadership for Building Effective Health Care Teams
Stephen H. Taplin , and colleagues
Background With the Affordable Care Act and other movements spurring team approaches, this article addresses the potential and challenges of using teams in health care.
What This Study Found For leaders to help create and support effective teams, they must know what conditions encourage effective functioning of a particular type of team in a particular setting. Leaders must be conscious of their role in shaping teams and recognize that creating effective teams requires their support, coaches who can facilitate team development, organizations that value teamwork, space that encourages teamwork, and leadership that rewards team performance.
Implications