Table of Contents
The Issue in Brief
Community Health Center Use After Oregon's Randomized Medicaid Experiment
Steffani R. Bailey , and colleagues
Background Will Community Health Centers (CHCs) experience increased demand from patients who gain health care coverage through the Affordable Care Act's Medicaid expansion? This study explores that question by examining primary care use over a three-year period in a population of low-income adult CHC patients who gained coverage when Oregon expanded its Medicaid program in 2008.
What This Study Found Analysis of data on 34,849 patients showed that Medicaid coverage significantly increased the rate of primary care visits, laboratory tests, referrals and imaging. Specifically, the number of primary care office visits per month was 282 per 1,000 Medicaid-covered patients, compared with 201 for patients without such coverage. In the 3-year follow-up period, Medicaid coverage led to a 58 percent higher rate of referrals, 27 percent higher rate of orders for laboratory tests and a 33 percent higher imaging rate.
Implications
- ACA insurance expansions could lead to increased demand for services from CHCs and other primary care settings. According to the authors, it will be important to ensure that the health care system can support increasing demands by providing more resources to CHCs and other primary care settings.
Andrew M. Ryan , and colleagues
Background There are many questions about how Accountable Care Organizations (ACOs)should be structured. This study examines one such structural issue: the approach practices in ACOs use to compensate primary care physicians.
What This Study Found Compensation arrangements for primary care physicians in ACOs are similar to those in practices that assume substantial risk for primary care costs. Based on physicians' compensation as the percentage of compensation based on salary, productivity, clinical quality or patient experience, and other factors, primary care physicians in ACO practices on average receive 49 percent of compensation from salary, 46 percent from productivity, 3 percent from quality and 2 percent from other factors. Physicians not in ACOs but with substantial risk for primary care costs receive two-thirds of their compensation from salary, nearly one-third from productivity and slightly more than 1 percent from quality and other factors. Although ACO practices provide higher compensation for quality compared with practices at large, they provide a similar mix of compensation based on productivity and salary.
Implications
- According to the authors, incentives for ACOs may not be sufficiently strong to encourage practices to change physician compensation policies for better patient experience, improved population health, and lower per capita costs.
Sleep Apnea and Risk of Panic Disorder
Kun-Ta Chou , and colleagues
Background Obstructive sleep apnea occurs when the throat muscles relax and block the airway during sleep. It has been linked to depression and other mental health issues. This study examines the relationship between sleep apnea and panic disorder.
What This Study Found Sleep apnea more than doubles the risk of developing panic disorder. Analysis of data from 8,704 sleep apnea patients and 34,792 control patients from the Taiwan National Health Insurance Research Database revealed that of the 43,496 patients, 263 (0.60 percent) suffered from panic disorder during a nearly 4-year follow-up period, including 117 (1.34 percent) from the sleep apnea cohort and 146 (0.42 percent) from the control group. There may be several explanations for the link between sleep apnea and panic disorder.
Implications
- The authors advise clinicians to be aware of possible panic disorder in sleep apnea patients.
Erectile Dysfunction and Undiagnosed Diabetes, Hypertension, and Hypercholesterolemia
Sean C. Skeldon , and colleagues
Background Previous research suggests that erectile dysfunction is an early indicator for cardiovascular disease. This study examines whether there is an association between erectile dysfunction and undiagnosed hypertension, hypercholesterolemia, or diabetes.
What This Study Found Erectile dysfunction doubles the odds of having undiagnosed diabetes. For an average man aged 40 to 59 years, the probability of undiagnosed diabetes jumps from one in 50 to one in 10 in men with erectile dysfunction. There is no association between erectile dysfunction and undiagnosed hypertension or hypercholesterolemia.
Implications
- The authors call for physicians to be vigilant in obtaining sexual histories in middle-aged men and screening those with erectile dysfunction for diabetes.
Correlates of Sexual Activity and Satisfaction in Midlife and Older Women
Holly N. Thomas , and colleagues
Background There is a strong link between a healthy sex life and higher quality of life as individuals age. This study of midlife development in women aged 28 to 84 years estimates sexual activity and identifies factors associated with sexual activity and sexual satisfaction.
What This Study Found A considerable proportion of midlife and older women remain sexually active if they have a partner available. Among older women who are sexually active, sexual satisfaction is related not to age or menopausal status, but to higher relationship satisfaction, better communication and higher importance placed on sex. Among women aged 60 and older who are married and cohabitating, 59 percent are sexually active. Overall, 62 percent of respondents report being sexually active in the previous six months, however, the proportion decreases with advancing age. Women who are cohabitating have approximately eight times higher odds of being sexually active; about 13 percent of sexually active women surveyed are not married or cohabitating.
Implications
- Many women maintain or want to maintain a satisfying sex life into middle age and beyond. The authors advise clinicians to ask women about sexual activity and sexual satisfaction and help them to maintain a satisfying sex life with aging.
Rates of Anomalous Bupropion Prescriptions in Ontario, Canada
Leah S. Steele , and colleagues
Background There are increasing reports of misuse of bupropion, a widely prescribed drug for the treatment of depression that can create a cocaine-like high when crushed, snorted or injected. This study explores prescribing trends for the drug in Ontario, Canada.
What This Study Found There is a marked increase in the number of potentially duplicitous prescriptions for bupropion after 2008, suggesting growing misuse of the drug. Specifically, researchers evaluated 1,780,802 prescriptions for bupropion, 3,402,462 prescriptions for citalopram, and 1,775,285 prescriptions for sertraline between 2000 and 2013. (The latter two are antidepressants not known to be prone to abuse.) While they found no differences in early refills between the three drugs, they found potentially duplicitous prescriptions for bupropion increased from less than 0.05 percent in early 2000 to 0.47 percent in early 2013. In contrast, over the same period, potentially duplicitous refills decreased for citalopram and sertraline.
Implications
- The authors conclude that these findings suggest a troubling phenomenon that bupropion prescriptions are being used recreationally at an increasing rate.
- Physicians and pharmacists are advised to be aware of the potential for bupropion misuse, particularly in patients prone to substance use disorders or who display unusual drug-seeking behaviors.
Exploring the Patient and Staff Experience With the Process of Primary Care
Elizabeth J. Brown , and colleagues
Background Surveys of patient experiences usually target Medicare and privately insured populations, leaving the lowest socioeconomic status patients' voices under-represented. This is the first qualitative study to assess the experience of both low income, chronically ill patients and the clinic staff who care for them during each step of the primary care process.
What This Study Found There are areas of agreement and tension between the needs and preferences of high-risk patients and staff in the primary care setting. Two major challenges frequently get in the way of an effective visit: 1) information flow, despite systems that are intended to improve communication and 2) misaligned goals and expectations among patients, clinicians and staff members. Personal relationships are highly valued by patients and staff.
Implications
- The authors conclude that when considering how to improve the care of vulnerable patients, it is important to focus on improving information flow, aligning goals and expectations, and developing personal relationships.
Catching Up With the HPV Vaccine: Challenges and Opportunities in Primary Care
Andrew L. Sussman , and colleagues
Background Rates of vaccination for human papillomavirus (HPV) are lower than rates for other teen vaccines. This study investigates a broad range of factors in health care delivery, health policy, and attitudes that influence HPV vaccination.
What This Study Found Interview and survey data from primary care clinicians, health policy makers and immunization experts reveal health service delivery challenges as the greatest barrier to HPV vaccination, specifically the inability to track and distribute reminders to eligible patients. Clinicians also report variations in counseling approaches due to patient age and emphasis on cancer prevention benefits of the vaccine. Sociocultural influences on vaccine decision-making and fear that adolescents would feel overprotected do not appear to be factors.
Implications
- The authors call for interventions targeting innovative communication techniques, as well as health system changes that build on efforts toward coordinated care and utilization of other venues to promote vaccination.
Impact of Cervical Cancer Screening Guidelines on Screening for Chlamydia
Mack T. Ruffin, IV , and colleagues
Background In 2009, a guideline change postponed cervical cancer screening to age 21. (Previously, the American College of Obstetrics and Gynecologists recommended beginning screening three years after first sexual intercourse or by age 21, whichever occurred first.) This study assesses if the guideline change had an effect on rates of chlamydia screening in women aged 15-21 years in primary care clinics.
What This Study Found Following the guideline change, there was a dramatic decrease in chlamydia screening among women aged 15 to 21 years. Women had higher odds of being screened for chlamydia before the guideline change compared to after. There was no corresponding decrease in office visits which could explain the reduced screening rates.
Implications
- The American College of Physicians recently recommended against performing screening pelvic examinations in nonpregnant, asymptomatic women. This recommendation, the authors warn, may affect chlamydia screening rates in a way similar to that of the change in cervical cancer guidelines. They conclude that chlamydia, pelvic examinations and cervical cancer screening need to be uncoupled and new screening opportunities should be identified.
David H. J. Pols , and colleagues
Background Physicians and researchers in family medicine often need to find relevant articles in online medical databases. For example, many physicians use databases to obtain biomedical information for clinical practice, however, the enormous volume and diversity of the available literature makes this a challenging process. A search filter may help improve the efficiency and quality of such searches. This study develops and validates search filters to identify research studies relevant to family medicine.
What This Study Found Researchers created and validated two highly sensitive and specific search filters. The specific search filter, which has a specificity of 97 percent and a sensitivity of 90 percent was developed to help family physicians find answers to clinical questions at the point of care when time is limited, providing the physician with references that are relevant, but with a small risk of missing articles. In contrast, the sensitive search filter, which has a sensitivity of 97 percent and a specificity of 75 percent, provides considerable efficiency while avoiding missing relevant articles and may be helpful to researchers conducting systematic reviews.
Accountable Communities for Health: Moving From Providing Accountable Care to Creating Health
Renuka Tipirneni , and colleagues
Background One of the aims of accountable care organizations (ACOs) is to improve the health of the population. Past efforts to build community-oriented primary care in the United States can offer insights into this process.
What This Study Found Lessons from community-oriented primary care could move ACOs, which are narrowly health care-focused, toward "accountable communities for health" (ACHs), integrating medical care, public health, and social services. Compared to ACOs, this approach could be more inclusive of the diverse determinants of health, with greater potential to improve population health. There are early examples of ACH models in Minneapolis, MN and Akron, Ohio.
Implications
- The authors suggest that by using the ACH model, ACOs have a roadmap for embedding health care in communities in a way that uniquely addresses local social determinants of health.
Adam O. Goldstein
What This Study Found A family physician reflects on the unexpected passing of an uninsured patient who become a continuity patient. He asserts that his patient died in part as a result of a health care system that has a messy patchwork of regulations mixed with politics. He reflects on how a lack of access to affordable health care profoundly affects patients and clinicians
Sean P. David , and colleagues
Background Genomic medicine may provide the greatest impact when systematically integrated with primary care, where most health care occurs, and where its delivery can be truly personalized. This report synthesizes insights from the Institute of Medicine Roundtable on Genomic-Based Research for Health and proposes a model for implementing genomic medicine into the patient-centered medical home (PCMH).
What This Study Found Implementation of clinical genomics into primary care and clinical practice has been limited because of critical evidence gaps, especially those related to clinical utility and applicability to diverse populations. A roadmap for integration could include three components: 1) evidence analysis and gap filling, 2) clinical implementation science, and 3) clinical implementation within a continuous improvement loop whereby clinical observations inform translational science and dissemination.
Implications
- To make personalized healthcare even more personal requires re-aiming translational pipelines towards more healing relationships in a continuously improving PCMH, which could enable realization of the primary care genomics partnership models envisaged by leaders in both fields.
Peter A. Selwyn
Background A family physician in the Bronx, NY, reflects on the history of a single mother with HIV for whom he has been caring for almost ten years.
What This Study Found A routine visit turns into a unique opening for communication and connection. A chance glimpse out of the window of the exam room following the visit inspires a deeper meditation on parenthood, survival and healing both for the family physician and his patient.