Table of Contents
The Issue in Brief
Solo and Small Practices: A Vital, Diverse Part of Primary Care
Winston R. Liaw , and colleagues
Background Solo and small practices are facing growing pressure to consolidate. This study sets out to determine the percentage of family physicians in solo and small practices and the characteristics of and services provided by these practices.
What This Study Found More than half of family physicians work in small and solo practices. Thirty-six percent of study respondents work in small practices and 15 percent work in solo practices. Small practices are the most likely to be located in a rural setting (20 percent). Small and solo practices are more common among African American, Hispanic and experienced physicians who have been in practice more than 30 years.
Implications
- Family physicians working in solo and small practices still outnumber those working in medium and large practices.
- These findings, the authors conclude, raise concerns about the types of physicians and communities that are being disproportionately affected by practice consolidation.
Large Independent Primary Care Medical Groups
Lawrence P. Casalino , and colleagues
Background In the turbulent U.S. health care environment, physicians are increasingly, choosing to become employed by large organizations, such as large multispecialty or single specialty medical groups. This opportunity is often not available, however, and many physicians are becoming employed by hospitals. For primary care physicians (PCPs), there is another option: the large physician-owned primary care medical group. Few physicians and policy experts are aware of these groups. In this article, the authors describe five large PCP groups and their advantages, disadvantages, and challenges.
What This Study Found Large independent physician-owned primary care groups offer physicians an attractive employment alternative to hospital or large multispecialty medical groups and can also benefit patients and society. The scale of the groups makes it possible for them to develop laboratory and imaging services, health information technology, and quality improvement infrastructure, while their multiple practice sites offer patients easy geographic access and the small practice environment that many patients and physicians prefer. The five groups studied had an average size of 148 physicians of whom 87 percent were primary care physicians. Unlike hospital-employed and multi-specialty groups, these independent groups can aim to reduce health care costs without conflicting incentives to fill hospital beds and keep specialist incomes high. Some, however, are under pressure to sell to organizations that could provide capital for additional infrastructure to engage in value-based contracting and provide substantial income to physicians from the sale.The groups' physicians reported only moderate satisfaction with their clinical workload and work-life balance, suggesting that the groups have not fully resolved the difficulties of practicing primary care medicine.
Implications
- The authors conclude that large independent primary care physician groups have the potential to make primary care attractive to physicians and to improve patient care by combining human scale advantages of physician autonomy and the small practice setting with resources that are important to succeed in value-based contracting.
Primary Care Physician Panel Size and Quality of Care: A Population-Based Study in Ontario, Canada
Simone Dahrouge , and colleagues
Background Where physician resources are scarce, one way to ensure that individuals have a primary care doctor is to promote larger panel sizes (i.e., more patients per doctor). There is a concern, however, that the quality of primary care may decline at larger panel sizes. This study examines the association between family physicians' panel size, quality of care, and health service use.
What This Study Found Among 4,195 physicians in Ontario, Canada with panel sizes between 1,200 and 3,900 patients, increasing panel size is associated with small decreases in cancer screening, continuity, and comprehensiveness, but little difference in chronic disease management quality or indicators of access to care. Specifically, the likelihood of patients? being up-to-date on cervical, colorectal and breast cancer screening shows relative decreases of 8 percent, 6 percent and 5 percent, respectively, with increasing panel size. Eight chronic care indicators show no significant association with panel size, but increasing panel size is associated with an 11 percent relative increase in hospitalization rates for ambulatory-care-sensitive conditions and an 11 percent decrease in non-emergency department visits. Continuity is highest with medium panel sizes and comprehensiveness has a small decrease with increasing panel size.
Implications
- According to the authors, these findings do not support policy measures such as thresholds or caps that reduce payments to physicians with large panel sizes.
- Physicians who take on larger patient panels may be able to do so without compromising care quality because personal or practice characteristics, such as communication style, organizational climate, and measures to optimize practice access, allow them to provide effective and efficient care.
Katrina J. Serrano , and colleagues
Background The growth of mobile devices offers new opportunities for patients and health care professionals to share health information electronically. This study looks at patients' willingness to electronically exchange different types of health information.
What This Study Found Patients are less willing to use mobile devices to exchange information that may be considered sensitive or complex. However, they are very willing to exchange appointment reminders, general health tips, medication reminders, laboratory test results, vital signs, lifestyle behaviors and symptoms. Regardless of the information type, older adults (aged 50 or older) have lower odds of being willing to exchange any type of information compared to younger adults (aged 18 to 34).
Implications
- The authors conclude that information type and demographic group should be considered when developing and tailoring mobile technologies for patient-provider communication.
Ramin Asgary , and colleagues
Background As the homeless population ages, they are at higher risk of developing hypertension (high blood pressure). This study assesses the rates and predictors of uncontrolled blood pressure among hypertensive homeless and non-homeless adults using New York City's shelter-based clinics.
What This Study Found There is an alarmingly high rate of uncontrolled hypertension among homeless adults. In this study, forty percent of homeless patients have uncontrolled blood pressure. In comparison, the rates of uncontrolled blood pressure among hypertensive adults who are under treatment are 20 percent (for those aged 40 to 59 years) and 25 percent (for those 60 to 79 years). Lack of health insurance is a strong predictor of uncontrolled blood pressure among homeless and non-homeless hypertensive adults using shelter-based clinics.
Implications
- Hypertension is less controlled among the homeless, who often lack social support and resources to cope with its complications.
- The authors call for comprehensive approaches to provide targeted social services, address psychosocial issues, and improve health insurance for the homeless, as well as strategies to prevent and address homelessness.
Weng-Yee Chin , and colleagues
Background There have been few cohort studies (which take place over time) examining the rate of depression in primary care patients. This study estimates the occurrence of depression and risk factors associated with depression symptoms among primary care patients in Hong Kong.
What This Study Found There is a high rate of new depression symptoms in Chinese primary care patients seeking care from physicians in a Hong Kong research network. Specifically, among 2,929 adult patients, there is a 5 percent cumulative incidence of positive screening for depression. Predictors include being female, coming from a lower-income household, being a smoker, having at least two other medical conditions, having a family history of depression, and having consulted a physician at least twice in the past month. The rate of depression is lower among patients seen by physicians with qualifications in both family medicine and psychological medicine, implying the possibility of a preventive benefit of seeing clinicians with joint training.
Implications
- The authors suggest that policies to enhance the training requirements of primary care physicians may help reduce the burden of depressive disorders in Hong Kong.
Prescription Opioid Duration, Dose, and Increased Risk of Depression in 3 Large Patient Populations
Jeffrey F. Scherrer , and colleagues
Background Recent research suggests that the risk of new onset of depression increases with longer use of opioid medication. It is unclear, however, whether opioid-related depression is a result of the dose prescribed, the length of time the medication is used, or both. With more than 200 million prescriptions for opioids written in the United States annually, researchers investigate the association between opioid use and the risk of depression
What This Study Found Opioid-related new onset of depression is associated with duration of use but not dose.The risk of new-onset depression with 31 to 90 days of opioid use ranges from 1.18 to 1.33; and in opioid use more than 90 days, ranges from 1.35 to 2.05. Dose is not significantly associated with a new onset of depression.
Implications
- According to the authors, opioids may cause short-term improvement in mood, but long-term use of more than 30 days carries a risk of new-onset depression.
- The authors call for further research to identify which patients are most vulnerable to opioid-related depression.
Pragmatic Method Using Blood Pressure Diaries to Assess Blood Pressure Control
James E. Sharman , and colleagues
Background Home blood pressure (HBP) is superior to clinic blood pressure in assessing blood pressure control. However, averaging all HBP values from patient records in order to assess blood pressure control is impractical in busy clinical practice. This study offers a new method for clinicians to assess a patient's home blood pressure.
What This Study Found If three or more of the last 10 home blood pressure readings are at least 135 mm Hg (the threshold for elevated blood pressure based on HBP), there is a tendency towards uncontrolled blood pressure and greater risk of total organ disease associated with hypertension. hypertension there is a propensity toward having uncontrolled blood pressure according to 24-ABP, as well as greater risk of target organ disease associated with hypertension (increased aortic stiffness, left ventricular relative wall thickness, and left atrial area, but lower left ventricular ejection fraction).
Implications
- According to the authors, this pragmatic approach using a summary statistic is a valid method for assessing blood pressure control.
- This approach could also encourage greater use of HBP monitoring and help patients achieve better blood pressure control.
Split-Session Focus Group Interviews in the Naturalistic Setting of Family Medicine Offices
Michael D. Fetters , and colleagues
Background When recruiting health care professionals to participate in focus group interviews, investigators encounter many challenges, including busy clinic schedules, recruitment, and getting candid responses from diverse participants. To address these challenges, researchers developed a split-session method for conducting focus groups in the practice setting.
What This Study Found In split-session focus groups, time is divided between sessions with the entire group and with subgroups. This format provides flexibility for researchers to collect data in the office setting while accommodating a practice's workflow needs as much as possible.
Implications
- Holding focus group interviews in the practice could increase rates of participation of both physicians and practice staff.
- Split-session focus group interviews allow efficiency and a greater degree of tailoring interview questions to subgroups.
William Ventres
Background n/a
What This Study Found A family physician shares his personal ethos of healing that is informed by seven supporting principles: dignity, authenticity, integrity, transparency, solidarity, generosity, and resiliency. The author invites students, residents and practicing physicians to reflect and discover their own ethos of healing and the principles that guide their professional growth, and he offers a short digital documentary for use as a reflective prompt to encourage personal and professional development.
Implications
Michal Shani
What This Study Found A family physician recounts his experience managing an extremely anxious patient, its influence on him, and some of his reflections on the white nights that followed. He is often kept awake by the thought that he may have forgotten something for one of his patients and worries that he could have done something better. Mistakes, or near-mistakes, lead to endless ruminations and white nights and sudden awakenings, but he concludes that concern for patients and white nights are an expected part of being a physician. The day the terrified awakenings cease, he writes, is when it's time to find a different profession.