Index by author
In Brief
Alan Katz , and colleagues
Background People who have lower socioeconomic status may have higher rates of hospitalization for ambulatory care-sensitive conditions (conditions for which some hospitalization can be avoided with successful management in the community). This study examines whether differences in patient demographics, ambulatory care use, or physician characteristics explain this disparity in avoidable hospitalizations.
What This Study Found Neither differences in the type of care nor the physicians providing the care are driving the disadvantaged to be hospitalized. Among 34,741 patients in Winnipeg, Manitoba, Canada, 2 percent of whom were hospitalized with an obstructive airway disease-related diagnosis during the two-year follow-up period, there was an approximately three-fold increase in the odds of being hospitalized in the lowest income group relative to the highest. After controlling for patient demographics, ambulatory care use and physician characteristics, the relationship between socioeconomic status and hospitalization remained virtually unchanged.
Implications
- Factors outside of direct contact with the health care system may lead to inequities in obstructive airway disease hospitalization.
- The authors conclude that these findings should remind clinicians and policy makers of the importance of social determinants of health and encourage the development of programs and policies that address the poverty associated with poor health outcomes
Robert L. Phillips, Jr , and colleagues
Background Illinois was an early leader in comprehensive Medicaid reform. In 2006, the state implemented a primary care case management program, Illinois Health Connect (IHC) and a disease management program, Your Healthcare Plus (YHP). The programs aimed to promote preventive care, reduce the redundancy of services through continuity of care with a primary care clinician, and improve the management of chronic diseases.
What This Study Found An analysis of claims and enrollment data from the Illinois Medicaid experiment between 2006 and 2010 finds the programs were associated with cost reductions, improved utilization patterns and generally improved quality. IHC and YHP were associated with 1) substantial increases in outpatient services; 2) larger decreases in inpatient and emergency services; 3) a reduction of total costs vs. projections; and 4) substantial improvements in most preventive and chronic care measures. Illinois Medicaid expanded considerably between 2004 (1,878,931 enrollees) and 2010 (2,705,291 enrollees). By the fourth year, the estimated rate of annual savings was 6.5 percent for IHC and 8.6 percent for YHP, with a cumulative Medicaid savings of 1.46 billion. Per-beneficiary annual costs fell in Illinois over the study period compared to those in states with similar Medicaid programs. Moreover, quality improved for nearly all metrics under IHC, and most prevention measures more than doubled in frequency. Medicaid inpatient costs fell by 31 percent and outpatient costs rose by 25 percent to 46 percent. Avoidable hospitalizations for IHC fell by nearly 21 percent and bed-days by nearly 16 percent. By 2010, emergency department visits declined by 5 percent.
Implications
- Although these results are robust and encouraging, the limited evaluation design calls for caution in making causal inferences.
- The authors advise interstate collaboration to help states learn from each other.
Engaging Primary Care Patients to Use a Patient-Centered Personal Health Record
Alex H. Krist , and colleagues
Background Electronic personal health records hold great promise for improving health, but implementation has been a challenge. This study examines cost-effective ways that small- to medium-sized primary care practices can effectively encourage patients to use online patient portals to access their personal health records.
What This Study Found In eight Virginia primary care practices, integrating promotion of patient portals into the office visit is more effective at increasing usage rates than mailing invitations and other costly advertising campaigns. Over the 30-month study period, 26 percent of the 112,893 patients who had an office visit created an account on the patient portal. Of patients who visited the practices in the final month, 33 percent had a new or preexisting account. This uptake is significantly greater than the 17 percent observed in previous research in which the portal was only promoted through mailings. One out of three patients aged 60 to 69 years enrolled, the highest use rate of any age group studied, and a key factor influencing use of the patient portal was having a comorbid condition; 33 percent of patients with chronic conditions created a patient portal account. Uptake was influenced by the adoption of a team-based approach to notify patients about the patient portal rather than relying solely on clinicians, as well as adding portal features to report laboratory test results and generate after-care summaries.
Implications
- By directly engaging patients to use a portal and supporting practices to integrate its use into care, primary care practices can match or surpass the usage rates achieved by large health systems.
Factors Influencing Family Physicians' Contribution to the Child Health Care Workforce
Andrew W. Bazemore , and colleagues
Background Family physicians are the usual source of care for more than one third of children in the United States, yet the absolute proportion of family physicians providing care to children declined from 78 percent in 2000 to 68 percent in 2009. Given the importance of ensuring access to primary care for all children, this study seeks to better understand the factors associated with the decline between 2006 and 2009, including demographic and geographic characteristics of family physicians who provide care to children.
What This Study Found Among 37,020 family physicians, the overall proportion providing care to children declined from 74 percent in 2006 and 2007 to 72 percent in 2008 and 68 percent in 2009. Younger age, female sex and rural location were all positive predictors of family physicians providing care for children. Family physicians practicing in a partnership were more likely to provide care to children than those in group practices, as were family physicians practicing in areas with a higher density of children, lower poverty or no pediatricians.
Implications
- Family physicians provide access to care for children in many rural, urban and underserved areas. Policy makers and leaders in the pediatric workforce concerned with providing care to children and families must help family physicians manage the burdens of increasing demands and incentives to care for adults.
Babette C. van der Zwaard , and colleagues
Background Consultations for forefoot pain are frequent in primary care, but there is little research to guide treatment options. This study investigates the effect of podiatric treatment versus standardized shoe advice on foot pain, foot disability, quality of life, and social participation.
What This Study Found Researchers in The Netherlands examined outcomes for 205 patients aged 50 years and older consulting for nontraumatic foot pain. Regardless of whether patients consulted a podiatrist or received standard shoe advice from an informational leaflet, foot pain and foot-related dysfunction improved over time.
Implications
- Based on these findings, the authors conclude that primary care physicians should be cautious when referring a patient to a podiatrist; instead they should start by providing advice on proper characteristics and fit of shoes.
Thijs Reyniers , and colleagues
Background Family physicians play a unique role in providing end-of life care and enabling terminally ill patients to die in familiar surroundings rather than in a hospital. This study explores family physicians' perceptions of their role and the difficulties they perceive in preventing and guiding hospital admissions at the end of life.
What This Study Found 39 family physicians in focus group interviews identified five complex roles that they assume in end of life care: 1) as a care planner, anticipating future scenarios; 2) as an initiator of decisions in acute situations, mostly in an advisory manner; 3) as a provider of end-of-life care in which competency and attitude is considered important; 4) as a provider of support, particularly by being available during acute situations; and 5) as a decision maker, taking overall responsibility.
Implications
- Enhancing the family physician's role as a gatekeeper to hospital services, offering physicians more end-of-life care training, and developing or expanding initiatives to support them, the authors conclude, could improve end-of-life care in general and prevent hospital admissions at the end of life.
The 5 R's: An Emerging Bold Standard for Conducting Relevant Research in a Changing World
C.J. Peek , and colleagues
Background The accelerated pressure for change in health care has created an exploding need for relevant and rapidly generated new information. The current slow and fragmented approach to research, however, often fails to address practical needs for decision making. This paper synthesizes several existing approaches and develops a new "5 R's" standard to guide research and help meet the changing needs of health care delivery.
What This Study Found The 5R's are intended to generate research that 1) is relevant to stakeholders, 2) is rapid and recursive in application, 3) redefines rigor, 4) reports on resources required, and 5) is replicable. The R's of the research process are mutually reinforcing and can be supported by training that fosters collaborative and reciprocal relationships among researchers, implementers, and other stakeholders.
Implications
- The 5R's can serve as a framework for discussion and adjustment of criteria for what is considered high-quality research. Consistent and bold application of this standard, the authors conclude, will increase the value, timeliness and applicability of the research enterprise.
Isabelle Vedel , and colleagues
Background The growing number of people with dementia and the burden it places on families makes dementia a global health priority. This study examines barriers to implementation of case management for dementia patients and the relationship between barriers and case management outcomes.
What This Study Found Two key conditions appear to significantly improve case management outcomes: high-intensity case management and effective communication among health care professionals and services caring for dementia patients. Five characteristics of high-intensity case management include: 1) a small caseload, 2) regular meetings with patients and caregivers, 3) education on health conditions, 4) close contact with family physicians, and 5) proactive and timely follow-up. Effective communication relies on an efficient referral system and timely support of family physicians and case managers by specialists in complex cases.
Implications
- The authors recommend evaluating case management implementation in health care facilities.
Alisha Liggett , and colleagues
Background Low voter turnout is a challenge in US elections. Disparities among voters is especially great among individuals who are likely to receive care at federally qualified health centers. This study develops a nonpartisan, clinician-led, voter registration initiative in two federally qualified health centers prior to the 2012 presidential election.
What This Study Found During a 12-week period, the initiative sought to register clinic patients to vote by engaging them in clinic waiting areas. Volunteers directly engaged with a total of 304 patients. Of the 128 patients who were eligible and not currently registered, 114 (89 percent) registered to vote through the project. Sixty-five percent of new registrants were younger than 40 years of age and nearly half of new voters were re-registrants because of changes in demographics, highlighting barriers in the current voter registration process.
Implications
- Clinics can help bring a voice to civically disenfranchised communities. In communities with high levels of socioeconomic stress, the authors suggest, easing access to voter services becomes increasingly important.
- This project demonstrates how health care professionals can address broader social determinants of health through clinic interventions. If health centers step up their role in community civic activism, the authors conclude, they can act as powerful vehicles for bringing a voice to communities underrepresented in the electoral process.
A Tale of 2 Countries: The Cost of My Mother's Cardiac Care in the United States and India
Sowmya R. Rao
Background A health services researcher compares the cost of surgical cardiac care in the United States and India after her Indian mother fell ill while visiting her in the United States.
What This Study Found The author describes the challenges she and her family faced in making well-informed decisions in the United States due to the lack of cost transparency and the minimal flexibility offered in the choice of care. They ultimately sought care in India, where cardiac specialty care is world-class, with comparable morbidity rates. In addition, cost information is readily available and significantly lower, and they were able to freely choose their type of care.
Implications
- The author asserts that "developed" countries have a lot to learn from the ways health care is delivered in "developing" countries.
- Increased transparency, the author concludes, is essential for choosing not only the hospital and provider of care, but also the appropriate course of action.
Interpreting Medicine: Lessons From a Spanish-Language Clinic
Benjamin P. Brown
Background n/a
What This Study Found A practicing physician examines how working with a predominantly Spanish population reminds him of the importance of understanding patients--not only in the literal sense of being able to understand the patient' language--but in a broader sense of having the courage to ask about the patients' struggles and to invest in helping them overcome them. Good physicians, he asserts work to forge a common language with all their patients, not only with those who do not speak English. He concludes that to become a doctor is also to become an interpreter.
Ruth Kannai
Background A practicing physician reflects on how a malpractice suit challenged her customary, patient-centered approach to care.
What This Study Found Sharing three vignettes from her practice, the author describes her inner dialogue both "preprosecution" and "postprosecution." She concludes that prosecuted doctors must not abandon their most fundamental contract with patients, which is to place them at the center, putting the patients' needs before their own and sacrificing their own comfort and security if necessary. She asserts that defensive medicine, often practiced by doctors to avert malpractice suits, sacrifices the patient's well-being for the emotional health and sound sleep of the doctor, sometimes at the cost of trying to shift the doctor's responsibility to the patient. And she tells how focusing on the needs of a single patient helped her to rediscover her perspective.