Table of Contents

The Issue in Brief

A Stepped-Wedge Evaluation of an Initiative to Spread the Collaborative Care Model for Depression in Primary Care

Leif I. Solberg , and colleagues

Background The "Depression Improvement Across Minnesota--Offering a New Direction (DIAMOND)" initiative tested implementation of the collaborative care model for depression in real-world practices. The study evaluated whether providing 75 primary care practices with payment change, intensive training, and support would improve patient-reported depression outcomes.

What This Study Found While the intervention improved patient satisfaction, it had little impact on other outcomes. Enrolled patients reported receiving more desired care processes, however, patients receiving DIAMOND care had neither better depression outcomes nor better improvement in work productivity or health status. Specifically, the study found that patients who received DIAMOND care reported more collaborative care depression services than three other comparison groups and more satisfaction with their care. Depression remission rates, however, were not significantly different among the four groups.

Implications

• These findings illustrate the difficulties of widespread implementation of evidence-based practices that require major changes in roles and extensive financial and leadership support.

Primary Care Patients Hastening Death by Voluntarily Stopping Eating and Drinking

Eva E. Bolt , and colleagues

Background Voluntary stopping of eating and drinking (VSED) is sometimes considered a feasible way to hasten death for people who suffer unbearably. This report from the Netherlands examines physicians' involvement with VSED to better understand the characteristics and motives of VSED patients and describe the duration and prevalent symptoms in the last days of life.

What This Study Found The survey of 285 family physicians revealed VSED is not uncommon in Dutch primary care and seems to be a relatively comfortable way to hasten death if sufficient palliative care is available. Specifically, the study found almost one-half of respondents had cared for a patient who hastened death by VSED, and that patients' motives to do so were both physical and psychosocial. Patients who decided to use VSED were mostly aged older than 80 years, in poor health, and dependent on others for everyday care. The median time until death was seven days, and the most common symptoms before death were pain, fatigue, cognitive decline and thirst or dry throat. Most patients electing VSED involved others for support; family physicians were involved in 62 percent of cases.

Implications

• The authors conclude that family physicians can play an important role in caring for VSED patients and their proxies by providing them with information, support and symptom management.

The Cost of Sustaining a Patient-Centered Medical Home: Experience From 2 States

Michael K. Magill , and colleagues

Background Transformation of a practice to a patient-centered medical home (PCMH) requires many changes, including new workflows, systems to improve patient access and manage patient health, and potentially added staff to perform new services. This study examines personnel costs necessary to deliver PCMH functions in a diverse group of practices in 2 states.

What This Study Found Even partial PCMH implementation costs approximately $105,000 per full time equivalent (FTE) physician annually. PCMH costs per physician FTE were $7,691 in Utah and $9,658 in Colorado, and PCMH incremental costs per patient encounter were $32.30 and $36.68, respectively. For an assumed panel of 2,000 patients, average estimated costs per member per month were $3.85 in Utah and $4.83 in Colorado.

Implications

• Maintenance and ongoing support of PCMH functions require additional time and new skills, which may be provided by existing staff, additional staff or both.
• The authors conclude that adequate compensation for ongoing and substantial incremental costs is critical for practices to sustain PCMH functions. Payment reform, they assert, is essential for primary care practices to sustain medical home services.

A Population-Based Study Evaluating Family Physicians' HIV Experience and Care of People Living With HIV in Ontario

Claire Kendall , and colleagues

Background Antiretroviral therapy (ART) for HIV infection has reduced death and disease and shifted the care needs of people living with long-term HIV. Early studies found that clinicians with more training and/or experience in HIV provided higher quality of care, but as the disease and treatments become less novel and complex, quality of HIV care between generalist and specialist physicians has become more similar. This 4-year study explores whether the HIV experience of family physicians effects the association between model of care delivery and the quality of care for people living with HIV.

What This Study Found Family doctors who take care of more HIV-positive patients in their regular practice are more likely to follow antiretroviral therapy protocols than other family doctors. Among more than 13,000 HIV-positive patients, the majority saw family physicians exclusively for their care. Those who saw a family physician with the highest level of HIV experience were almost twice as likely to receive ART than those seeing less experienced family physicians. Cancer screening and health service use were not influenced by family physician HIV experience. The influence of family physician HIV experience appears to be mitigated by having an HIV specialist in the model of care.

Implications

• The authors conclude that to ensure adequate ART prescribing, care delivery models for people with HIV should include either an HIV specialist or a family physician with considerable HIV experience.

Prevalence, Correlates, and Outcomes of Multimorbidity Among Patients Attending Primary Care in Odisha, India

Sanghamitra Pati , and colleagues

Background Multimorbidity (having two or more chronic conditions) is linked to higher health care utilization and expenditures and worse quality of life. Information on multimorbidity in developing countries is limited. This is the first study to estimate the prevalence of multimorbidity among adult primary care patients in India, specifically in the state of Odisha.

What This Study Found Almost 30 percent of primary care patients in Odisha, India have multiple physical and mental health problems, a finding that is consistent with prevalence studies around the world. Twenty-eight percent of patients had two or more chronic conditions. Patients who were female, older, of higher socioeconomic status, and more educated had higher odds of having multimorbidities. In addition, consultation in private versus public hospitals and more chronic conditions were associated with a significant increase in the number of medicines prescribed. India?s higher prevalence of multimorbidity and hospitalization among those with higher socioeconomic status contrasts with Western countries where lower socioeconomic status is associated with greater morbidity burden. This might be attributed to contrasting socioeconomic patterns of risk factors for noncommunicable diseases in India and lower health care seeking and higher probability of underdiagnosis in low-income populations.

Implications

• The authors call for India to redesign national health programs, shifting the focus from single diseases to managing the complexity of multimorbidity.

Primary Care Physician Insights Into a Typology of the Complex Patient in Primary Care

Danielle F. Loeb , and colleagues

Background New models of patient complexity have been developed, but it is not known if primary care physicians' (PCPs) perceptions of complexity are consistent with these models. This study set out to understand how PCPs conceptualize patient complexity.

What This Study Found In-depth interviews with 15 primary care physicians from two university clinics and three community health centers revealed a multidimensional concept of patient complexity. The physicians perceived patients to be complex if they had one or more exacerbating factors--a medical illness, mental illness, socioeconomic challenge or behavior or trait--that complicated care for chronic medical illnesses. Most of the physicians broadly defined complex patients as those who did not easily fit into guidelines or algorithms.

Implications

• The authors suggest that insights offered by physicians in this study integrate well into two recently proposed conceptual models: AHRQ's Multiple Chronic Conditions Research Network model and a model based on comorbidity interrelatedness developed by Zulman et al.
• The perspectives offered by physicians in this study can help refine existing models of complexity and better inform the organization of care for complex patients, according to the authors.

A Participatory Model of the Paradox of Primary Care

Kurt C. Stange , and colleagues

Background The discrepancy that exists between apparently poor disease-specific care for individuals and advantageous outcomes at the level of the whole person and system has been called the paradox of primary care. To explore and test mechanisms that might account for this paradox and try and explain the effects of primary care beyond disease-specific care, researchers developed a novel computer simulation model with input from patients, caregivers, and primary care clinicians.

What This Study Found The resulting model identifies some of the key features of primary care. Participants used the computer model to test hypotheses about how different primary care mechanisms can combine to add value beyond disease treatment and how these mechanisms can affect the health of different types of people. Using the model, the paradox persisted: where there was complexity and adequate primary care, patients did better, yet patients with single health problems did better in specialty care. Specifically, in a model run with the primary care features turned off, the group found primary care patients had poorer health. In a model run with all primary care features turned on, primary care patients who sought primary care had better population health, with a particularly pronounced effect for patients who were disadvantaged and had multiple chronic conditions.

Implications

• The model allows users to develop and test hypotheses that would be difficult or impossible to test in the real world.
• Insights gleaned from these efforts, the authors conclude, can be used not only to develop more sophisticated models, but to guide empirical research and advance a more nuanced understanding of the value of primary care and the possible complex interactive mechanisms by which that value emerges over time.

Managing Patients With Heart Failure: A Qualitative Study of Multidisciplinary Teams With Specialist Heart Failure Nurses

Margaret Glogowska , and colleagues

Background Recognizing that management of patients with heart failure is uniquely challenging, researchers in the United Kingdom explored the perceptions and experiences of clinicians working in multidisciplinary teams that include specialist heart failure nurses whose serve as caseworkers. These experienced senior nurses become involved with patients at the initial diagnosis of heart failure and continue for the course of the patients? illness, offering medical, psychological, and emotional support.

What This Study Found The 24 clinicians interviewed identified two areas that represent particular challenges when working with heart failure patients: 1) communication with patients, in particular, explaining the diagnosis and helping patients understand the condition, and 2) communication within the care team to coordinate multidisciplinary involvement in managing patients' treatment regimens. All of the interviewed clinicians regarded specialist heart failure nurses as the lead clinicians for their patients, helping to ensure coordination, continuity, and quality of care. The nurses were perceived as being able to bridge the gap between primary and secondary care by ensuring recommendations from specialist physicians were acted upon and by taking the lead in medication issues so that prescribing decisions reflected input from secondary care providers.

Implications

• These findings highlight the critical role of specialist heart failure nurses in delivering tailored education to patients and facilitating better liaison among clinicians to ensure better quality of care. According to the authors, the way in which these nurses serve as caseworkers is vital in ensuring coordination and continuity of care for heart failure patients.

Learning From No-Fault Treatment Injury Claims to Improve the Safety of Older Patients

Katharine A. Wallis

Background Patient safety is an urgent issue, particularly in the aging population and vulnerable elderly. Claims data from New Zealand's no-fault accident insurance program presents novel opportunities for learning from all types of patient safety incidents.

What This Study Found The greatest threat to older patients' safety in primary care is the risk posed by treatment itself, not error. Examination of four years of primary care treatment injury claims data showed that antibiotics were the biggest threat to safety and thus a key target for injury prevention initiatives. Most medication injuries were allergic and idiosyncratic reactions, for which there was no suggestion of error.

Implications

• The author concludes that to improve patients' safety, we need to look beyond reducing error to reducing patients? exposure to treatment risk where appropriate ? in particular the risk posed by medication, especially antibiotics.

Overcoming Challenges in the Changing Environment of Practice-Based Research

Stacia Finch , and colleagues

Background Conducting studies in national practice-based research networks presents logistical and methodological challenges. Research participants in Pediatric Research in Office Settings, the practice-based research network of the American Academy of Pediatrics, describe practical strategies they used to overcome these barriers in a national study.

What This Study Found Key challenges in the changing environment of practice-based research include identifying and recruiting practices, enrolling and screening participants, and achieving an acceptable phone interview response rate. Strategies employed and lessons learned in a recent study included the following. 1) When enrolling a specific population, it is cost-effective and time-efficient to survey potential participating practices beforehand to determine if the sites will serve the expected number of subjects. 2) The process of hiring and placing Research Assistants (RAs) in practices from a distance is a novel approach and a challenging solution. Using RAs to complete screening, consenting, and enrolling of parents, made participation easier for practice staff and practitioners. 3) Although the strategy of using RAs was successful, it was also costly--an additional lesson learned for planning future work. 4) Texting as a response method appears to be feasible, a potentially cost-saving innovation as well as a way to boost study power.

Implications

• The authors assert that the strategies they used to address research challenges can assist research networks in conducting future outcomes studies and practical clinical trials in primary care settings.

Cancer Risk Assessment Tools in Primary Care: A Systematic Review of Randomized Controlled Trials

Jennifer G. Walker , and colleagues

Background Risk assessment tools can be used in primary care to identify those most likely to benefit from tailored prevention efforts. This is the first systematic review of randomized controlled trials implementing cancer risk tools in primary care.

What This Study Found Although cancer risk assessment tools may increase patients' risk perception, knowledge, and screening intentions, they do not necessarily change screening behavior. Overall, use of a tool was greater if initiated by patients, if used by a dedicated clinician, and when combined with decision support. Health promotion messages within the tool demonstrated positive effects on behavior change.

Implications

• The findings suggest that while risk tools may increase actual intentions to have cancer screenings, additional interventions at the clinician or health system level may be needed to increase risk-appropriate cancer screening behavior.

I'm a Doctor. Can I Help?

Jonathan Emerson Kohler

For a young physician, reflecting on the opportunity to care for an accident victim at the scene reinforces the remarkable thing it is to be a physician.