Index by author
In Brief
Frequency and Prioritization of Patient Health Risks from a Structured Health Risk Assessment
Siobhan M. Phillips , and colleagues
Background Because behavioral factors help determine health, it is important to assess patient-reported health behaviors and psychosocial well-being. The My Own Health Report (MOHR) is a new electronic or paper-based health behavior and mental health risk assessment and feedback system. In preparation for integrating the MOHR into practice, this study examined the frequency of patient risk factors, the average number of risk factors per patient, and patients' perceptions of importance, readiness to change and desire to discuss identified risks with clinicians.
What This Study Found Patients reported a consistently high number of health risks, with more than one-half of patients reporting six or more risk factors. Despite the high number of health risks, most patients were not ready to change any risk factors and few wanted to discuss risk factors with their clinicians. The most common risk was poor diet (low fruit and vegetable consumption, frequent fast food consumption or frequent sugary beverage consumption), followed by overweight/obesity. Patients were most ready to change body mass index and depression and most wanted to discuss depression and anxiety or worry.
Implications
- These findings present a challenge, given the small amount of time available for prevention in primary care, and support the need for more integrated care.
- The authors suggest the need for routine administration of health risk assessments in primary care, the importance of real world approaches for implementing their findings and connecting patients and practices to appropriate resources, and the potential added value of including patients' perspective in the allocation of these resources.
The Cluster-Randomized BRIGHT Trial: Proactive Case Finding for Community-Dwelling Older Adults
Ngaire Kerse , and colleagues
Background Researchers in New Zealand assessed the effectiveness of a case finding strategy, which uses a screening survey?the Brief Risk Identification Geriatric Health Tool (BRIGHT)?to identify older adults with disability and refer them to geriatric services if necessary, as the first in a two-step process aimed at reducing disability and improving outcomes among older patients.
What This Study Found The BRIGHT screening intervention successfully identified older adults in need and increased residential care placement, but did not reduce the use of acute hospital services. After 36 months, patients in the intervention group who used the annual screening tool were more likely than those in the control group to have been placed in residential care. In addition, intervention patients had smaller declines in average scores for physical health-related quality of life and psychological health-related quality of life. Hospitalization, disability, and use of services, however, did not differ between groups.
Implications
- The case-finding strategy was effective in increasing identification of older adults with disability, but there was little evidence of improved outcomes.
- The authors call for further research to test primary care integration strategies.
Alex H. Krist , and colleagues
Background Guidelines recommend screening patients for unhealthy behaviors and mental health concerns. While health risk assessments can identify patients' needs and initiate care, it is not clear whether primary care practices can routinely implement such assessments. This study examines the experiences of nine primary care practices implementing the My Own Health Report (MOHR), a new electronic or paper-based health behavior and mental health risk assessment and feedback system to support counseling and goal setting.
What This Study Found Although practices were willing and able to implement the behavior and mental health assessments, most lacked the capacity and infrastructure to do so without additional support once the trial ended. Most practices agreed to adopt MOHR, and one-half of the 3,591 patients who were approached, completed the assessment. Reach varied by implementation strategy, with higher reach when MOHR was completed by staff than by patients. The observed reach of 50 percent was double the completion rates previously published by large health systems and on par with worksite completion rates coupled with economic incentives. In addition, practices were successful in getting patients of all ethnic, racial and socio-economic levels to participate in MOHR. Fielding MOHR increased staff and clinician time an average of 28 minutes per visit. As a result, no practices were able to sustain the complete MOHR assessment without adaptations after study completion.
Implications
- Most primary care practices are overwhelmed by competing demands, and typical office visits provide little time to address health risk information. As a result, more substantial practice transformation will be necessary to routinely integrate assessments such as MOHR into primary care.
- Current incentives for practice transformation are insufficient to facilitate this practice change. For example, according to the authors, mandating that health risk assessments be added to an already packed wellness visit increases the chances that practices will do it poorly or not at all.
Impact of Continuity of Care on Mortality and Health Care Costs: A Nationwide Cohort Study in Korea
Dong Wook Shin , and colleagues
Background Continuity of care, defined as an ongoing partnership between patient and clinician, is considered a core element of high-quality primary care, but its impact on mortality and health care costs is unclear. This study aims to determine the impact of continuity of care on mortality and health outcomes and costs in patients with newly diagnosed cardiovascular risk factors.
What This Study Found The study found that continuity of care is associated with reduced mortality, morbidity, and health care expenses and may provide added value in the management of chronic conditions. In particular, the study examined a random sample of more than 1,000,000 Korean National Health Insurance enrollees, 47,433 of whom had received new diagnoses of hypertension, diabetes, hypercholesterolemia or other complications. Evaluating the association of three standard indices of continuity of care with patients' overall mortality, cardiovascular mortality, incident cardiovascular events and health care costs over five years, lower indices of continuity of care were associated with higher all-cause and cardiovascular mortality, cardiovascular events and health care costs. Lower continuity of care was associated with increased inpatient and outpatient days and costs.
Implications
- While the findings cannot be generalized to other conditions, the results suggest that continuity of care is a robust predictor of outcomes in patients for conditions with available preventive interventions.
- The authors suggest that, with increasing fragmentation of health care systems and importance of cost containment, health care systems should be designed to support longer-term trusting relationships between patients and physicians, and health policies should encourage patients to concentrate their care with one physician.
Julie P. Phillips , and colleagues
Background The study re-examines the relationship between educational debt and primary care specialty choice, with a particular focus on how debt interacts with students' socioeconomic status.
What This Study Found High medical school debt discourages graduates of public medical schools from pursuing careers in primary care, but does not appear to influence private school graduates in the same way. Analysis of data from 136,232 physicians who graduated from US medical schools between 1988 and 2000 found physicians who graduated from public schools were most likely to practice primary care and family medicine at graduating educational debt levels of $50,000 to $100,000. At higher debt, graduates' odds of practice primary care or family medicine declined. In contrast, private medical school graduates were not less likely to practice primary care or family medicine as debt levels increased. They authors offer two possible explanations: 1) graduates with little or no debt may be less likely to choose primary care because they often come from wealthier families, and 2) public school graduates with very high debt are less likely to choose primary care because they perceive a need for the higher financial return of specialization to finance their debt.
Implications
- Reducing the debt of selected medical students may be effective in promoting a larger primary care physician workforce.
Pierre Tousignant , and colleagues
Background This study assesses two new measures of continuity of care, both versions of known provider continuity, which are easily measured in administrative databases. The measures capture the concentration of care from year to year with multiple physicians (KPC-MP) or a particular physician (KPC-PP), making them a potentially valuable and low cost-way to follow the effects of changes favoring group practice on continuity of care.
What This Study Found Analyzing survey and medical records data from 765 patients with diabetes or cardiovascular disease attending 28 primary care clinics in Quebec, Canada, researchers found KPC-MP was significantly related with a validated measure of overall care coordination and a combined continuity score summarizing five different validated survey measures. This is the first time a continuity measure that can be obtained from administrative databases has been found to be associated with a patient-reported measure of care coordination. Conversely, KPC-PP (year-to-year continuity with the physician seen most often) did not appear strongly related to patient-perceived measures of continuity.
Implications
- At a time of major primary care reorganization involving multiple health care professionals, KPC measures based on administrative databases could become a valuable way to do research on continuity.
Two Techniques to Make Swallowing Pills Easier
Walter E. Haefeli , and colleagues
Background More than one-half of people experience swallowing difficulties when taking tablets or capsules. This study evaluates two techniques for swallowing tablets and capsules.
What This Study Found Two techniques notably improve the ease of swallowing tablets and capsules in patients with and without swallowing difficulties. In the first, the pop-bottle method, the tablet is placed in the mouth, the lips are tightly closed around the opening of a flexible plastic beverage bottle and the tablet is swallowed in a swift suction movement. In the second, the lean-forward technique, capsules are swallowed in an upright position with the head bent forward. The pop-bottle method substantially improved swallowing of tablets in 60 percent of participants and the lean-forward technique in 89 percent.
Implications
- Both techniques were highly effective in participants with and without reported difficulties swallowing pills and can be recommended regularly.
Patient-Controlled Taping for the Treatment of Ingrown Toenails
Koichi Tsunoda , and colleagues
Background In this study, two primary care clinicians in Japan share a novel taping method to treat and prevent ingrown toenails.
What This Study Found Of 541 patients who were instructed in the use of the taping technique, 276 saw their symptoms and abnormal nail grown resolve and required no additional therapy. The remaining 265 patients required additional treatment such as nail bracing or surgery. Most of those patients reported relief of pain with taping. With conventional taping methods, most patients are required to visit a clinic frequently for re-taping and may discontinuing taping because of discomfort and skin irritation. The authors assert the new taping method is both easy and comfortable for patients and prevents circulatory problems and dermatologic side effects.
Implications
- The authors suggest that this non-invasive, low-cost approach be considered as a first-line treatment for ingrown toenails among primary-care patients before cutting or removing the nail.
Hospitalized Women?s Willingness to Pay for an Inpatient Screening Mammogram
Waseem Khaliq , and colleagues
Background With 40 percent of hospitalized women not up to date with breast cancer screening, this study examined whether and how much money hospitalized women would be willing to contribute towards the cost of an inpatient screening mammogram.
What This Study Found Among 193 hospitalized women amenable to inpatient screening, most were willing to contribute money to offset the cost of screening mammography. Specifically, 72 percent of women were willing to pay an average of $83.41 in advance toward inpatient screening mammogram costs. The authors suggest that this may not be a surprising finding because some of the barriers women face when attempting to have a mammogram (difficulty arranging transportation, forgetting to schedule the test, desire to avoid losing time at work, etc.) are less relevant when the mammography is performed during hospitalization.
Implications
- The authors suggest offering mammograms to nonadherent hospitalized women, especially those who are at high risk of developing breast cancer.
Health Information Technology: An Untapped Resource to Help Keep Patients Insured
Heather Angier , and colleagues
Background This essay suggests that health information technology is an untapped resource to support practice-based efforts to help patients obtain and maintain health insurance coverage. The authors present a conceptual model and strategies for harnessing health information technology to support insurance enrollment and retention. They also describe insurance support tools that could be used to conduct 'inreach' and 'outreach' with patients around health insurance, similar to how health information technology is used to manage chronic disease and panels of patients and to improve population health outcomes.
From Triple to Quadruple Aim: Care of the Patient Requires Care of the Provider
Thomas Bodenheimer , and colleagues
Background In light of the essential and underappreciated peril imposed by health care workforce burnout and dissatisfaction, this essay suggests adding the goal of improving the work life of health care clinicians and staff as a fourth element necessary to achieve the Triple Aim goal of enhancing patient experience, improving population health and reducing costs. Burnout is associated with lower patient satisfaction and reduced health outcomes, and may increase costs. The authors offer several practical steps health care organizations can take to address this proposed fourth aim.