Table of Contents
The Issue in Brief
Ann Fam Med 15: 102.
The Issue in Brief
Access to Primary Care Appointments Following 2014 Insurance Expansions
Karin V. Rhodes , and colleagues
Background The number of newly insured individuals in the US reached 20 million by early 2016 and has continued to grow. This has raised concerns about whether the primary care system can absorb millions of new patients seeking care.
What This Study Found There is no evidence as of mid-2014 that the millions of individuals newly covered through Medicaid and the Patient Protection and Affordable Care Act strained primary care capacity. This was demonstrated by stability in appointment rates and wait times for new, privately insured patients and an increase in appointment access for new Medicaid patients in 10 study states. An audit of simulated patient calls to primary care practices for new-patient appointments found overall appointment rates for private insurance remained stable from 2012 to 2014 with Massachusetts and Pennsylvania experiencing significant increases. Medicaid appointment rates increased 10 percentage points with substantial variation by state. Across all callers, median wait times for those obtaining an appointment were seven days in 2012 and five days in 2014, but the difference was not statistically significant. In addition to the possibility that there was sufficient capacity to absorb the new patients, the authors posit several alternative explanations for not finding a decline in primary care availability despite the millions of newly insured. Possibilities include efficiencies created by components of the Patient-Centered Medical home model such as team-based care, after-hours and weekend care, electronic medical records, and telephone and e-mail communications; and broad trends in care reorganizations such as Accountable Care Organizations, alternative payment arrangements, and practice mergers that provide economies of scale.
Implications
- The authors conclude it will be important to continue tracking appointment availability and wait times in primary care.
Jonathan Penm , and colleagues
Background Care coordination (organizing patient care activities and sharing information among participants) is a key strategy for improving the effectiveness, safety and efficiency of health care systems. This study examines care coordination in 11 high-income countries.
What This Study Found One out of every three respondents experienced at least one coordination gap in primary care, but the overall percentage reporting poor primary care coordination was low. Among the 11 countries evaluated, the United States had the highest rate of poor primary care coordination. Among patients in Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, United Kingdom and the United States, the rate of poor primary care coordination was 5 percent overall and highest in the US at 10 percent. Patients were less likely to experience poor care coordination if their primary care physician knew them well, spent sufficient time with them, involved them in care, and explained things well. Poor primary care coordination was more likely to occur among patients with chronic conditions and patients younger than 65 years. In the US, patients reported similar levels of poor primary care coordination regardless of insurance status, health status, income level and sex, suggesting a systemic issue that distinguishes the efficacy of primary care coordination from that of other countries.
Implications
- The authors note that care coordination gaps have been associated with a higher risk of patients experiencing a medical error, more follow-up appointments, and unnecessary health care spending. They conclude these findings warrant increased efforts to support relationships between primary care providers and patients, especially those who are younger and chronically ill.
Thirty-Minute Office Blood Pressure Monitoring in Primary Health Care
Michiel J. Bos , and colleagues
Background Automated office blood pressure monitoring for a period of 30 minutes (OBP30) has been proposed as an alternative method for assessing sustained hypertension, since it yields almost the same results as daytime ambulatory blood pressure monitoring and is much more convenient. This study compares OBP30 with routine office blood pressure (OBP) readings in primary care and evaluates how OBP30 influences medications prescribed by family doctors.
What This Study Found In-office automated blood pressure monitoring over 30 minutes (OBP30) yields considerably lower blood pressure readings than office blood pressure in all patient groups studied. It also reduces the number of patients who meet the criteria for intensification of antihypertensive medication regimes. The differences between office blood pressure and OBP30 were larger for patients aged 70 years or older. Based on OBP alone, physicians said they would have started or intensified hypertension medication in 79 percent of studied cases, but with the results of OBP30 available, this number was only 25 percent.
Implications
- OBP30 yields lower blood pressure readings than routine OBP in primary care and leads to an important reduction in medication prescriptions.
Nick A. Francis , and colleagues
Background This study assesses whether oral or topical antibiotics, in addition to standard treatment with topical corticosteroids, are more effective than placebo in reducing eczema severity in children with clinically infected eczema.
What This Study Found Estimates suggest that 40 percent of eczema flares are treated with topical antibiotics, but findings from this study suggest there is no meaningful benefit from the use of either oral or topical antibiotics for milder clinically infected eczema in children. There was rapid resolution in response to mild-to-moderate strength topical corticosteroids and emollient treatment; clinically meaningful benefit from the addition of either oral or topical antibiotics was ruled out. Because the study excluded patients with severe infection, the results may not be generalizable to all children with clinically infected eczema.
Implications
- The authors conclude that topical antibiotics frequently used in outpatient care, especially in combination products with topical corticosteroids, are not beneficial to patients with clinically infected eczema and can actually promote resistance and allergy or skin sensitization. They suggest that providing or stepping up the potency of topical corticosteroids and emollients should be the main focus in the care of milder clinically infected eczema flares.
Catherine Laporte , and colleagues
Background There have been few studies of brief primary care interventions for cannabis use by young people. This study examines whether a brief primary care intervention for young cannabis users leads to a decrease in consumption, regardless of their initial consumption level.
What This Study Found A brief motivational interview following the FRAMES (feedback, responsibility, advice, menu, empathy and self-efficacy) model shows some effectiveness for users aged under 18 years and for moderate nondaily users, but no effect in the study population overall. Specifically, after one year, there was no significant difference between the intervention and control groups in the number of joints smoked per month among all users, but there was a difference in favor of the intervention among nondaily users. After six months, the intervention was associated with more favorable change from baseline in the number of joints smoked and among users aged younger than 18 years, smoking fewer joints per month.
Implications
- The authors conclude that these findings support the use of a brief intervention in primary care for younger users and moderate users.
Robert L. Phillips, Jr , and colleagues
Background Previous research has demonstrated that Medicare beneficiary spending reflects that of the 306 Hospital Referral Regions where physicians train. Because these large areas have as much cost variation within as between them, this study sought to determine whether the relationship holds true for smaller areas and for quality.
What This Study Found Based on 2011 Medicare claims data for a nationally representative sample of family physicians and general internists who completed residency training between 1992 and 2011 at the level of the 3,436 US Hospital Service Areas (HSA), spending patterns for Medicare beneficiaries for whom they provided care were similar to the patterns of the HSA in which their sponsoring institution was located. There was no similar relationship for quality.
Implications
- The authors conclude these findings of a long-term "imprint" of training support efforts to test interventions in residency training that may bend imprinting toward teaching and modeling behaviors that improve value in health care.
Tammy C. Hoffmann , and colleagues
Background Antibiotics are too often prescribed for acute respiratory infections, despite strong evidence they typically provide only marginal benefit. This study explores parents' expectations and experiences using antibiotics for pediatric respiratory infections.
What This Study Found Most parents believe antibiotics provide benefits for common acute respiratory infections, particularly acute otitis media, although not using them, particularly for acute cough and sore throat, is sometimes acceptable. Parents grossly overestimate the benefit of antibiotics in reducing the duration of illness by five to 10 times, and many believe they reduce the likelihood of complications, especially for otitis media. The large majority recognize antibiotics may do harm, although there is confusion among many about what resistance actually is. Fewer than one-half of those interviewed recall discussing benefits and harms and the option of forgoing antibiotic use with their clinician, and 75 percent would like more involvement in future decisions.
Implications
- The authors suggest adopting shared decision making to address overly optimistic expectations of antibiotics and antibiotic harms.
Gregory A. Doyle , and colleagues
Background In the general population, hand washing can lower the risks of respiratory infections, eye infections, diarrhea, intestinal problems, pneumonia, and impetigo. This study examines a new "co-washing" initiative aimed at improving hand-washing rates among both physicians and patients in a busy outpatient clinic.
What This Study Found Co-washing appears to be effective at improving hand-washing rates. After implementation of the new procedure in which clinicians offered hand sanitizer to patients and also used the sanitizer to wash their own hands in front of the patient, patients stated doctors washed their hands 99.5 percent of the time before examining them, compared to 96.6 percent of the time before the intervention. Patients also reported washing their hands more often after the intervention.
Implications
- The authors call for further research to determine whether co-washing enhances clinic hand washing or hand washing at home by patients, and whether it can reduce infection rates.
Joann G. Elmore , and colleagues
Background Electronic medical records offer patients access to their medical data, including doctors' notes, and can facilitate increased patient involvement in their health care and contributions to their health data
What This Study Found Allowing patients to type their visit agenda into their electronic medical record before an office visit appears to facilitate communication of health concerns. Among 101 patients who typed their agenda into the electronic medical record visit note and their 28 clinicians, both patients and clinicians felt the agendas improved patient-clinician communication. Both expressed a desire to continue having patients type agendas in the future. The agendas themselves were brief; 83 percent of patients typed for less than 10 minutes, and 79 percent typed less than 60 words.
Implications
- Enabling patients to type visit agendas may enhance care by engaging patients, increasing the collaborative nature of the clinical encounter, and giving clinicians an efficient way to prioritize patients' concerns and optimize their time together.
Heather P. Whitley , and colleagues
Background With millions of Americans unknowingly living with chronic high blood sugar, there is a need to more quickly and easily identify and treat patients with unknown hyperglycemia. Standard screening, which typically uses fasting blood glucose measured through a chemistry panel, can be inconvenient, highly variable and can delay care. By contrast, HbA1c testing is durable and more accurately reflects sustained hyperglycemia. This study compares these two approaches for identifying patients with chronic hyperglycemia.
What This Study Found Systematically offered HbA1c point-of-care testing is superior to standard practice, according to study findings. Specifically, standard practice screened only 22 percent of patients, most commonly by blood glucose. Comparing glycemic outcomes, in the standard practice arm, six patients were found to have diabetes and 24 patients were found to have prediabetes. By contrast, point-of-care HbA1c screening identified 104 patients with diabetes and 88 patients with prediabetes.
Implications
- The authors conclude that because point-of-care HbA1c testing effectively identifies individuals early in the course of the disease and allows for immediate assessment, patient education and early management, it is superior for identifying unknown chronic hyperglycemia, particularly prediabetes.
The PCORI Engagement Rubric: Promising Practices for Partnering in Research
Laura Forsythe , and colleagues
Background Engaging patients, caregivers, and other health care stakeholders as partners in planning, conducting, and disseminating research is a promising way to improve clinical decision making and outcomes. However, many involved in research lack clarity about when and how to engage as partners in the clinical research process. The PCORI Engagement Rubric, developed by the Patient-Centered Outcomes Research Institute (PCORI), offers a framework for operationalizing stakeholder engagement in research.
What This Study Found The PCORI Engagement Rubric includes: principles of engagement; definitions of stakeholder types; key considerations for planning, conducting and disseminating engaged research; potential engagement activities; and examples of promising practices from PCORI-funded projects.
Implications
- This rubric is intended to help shift the research paradigm from one of conducting research on patients as subjects to a pursuit carried out in collaboration with patients and other stakeholders to better reflect the values, preferences, and outcomes that matter to the patient community.
Looking Within: Intentions of Practice for Person-Centered Care
William B. Ventres
Background In this essay, a physician reflects on intentions of practice: habits of mind that encourage him to attend to patients as complex human beings. These intentions help the author navigate interactions with patients and families in ways that are both efficacious and therapeutic.
What This Study Found The author describes seven intentions of practice: recognizing patients as whole people, practicing honestly with others and oneself, accepting what emerges in the clinical encounter, sharing the responsibility of care, being calm in the face of uncertainty, working to protect patients, and being authentic. When routinely recalled and adeptly implemented, these intentions help him integrate the biological, social and existential dimensions of care into his day-to-day clinical encounters with patients.
Implications
- The author reflects on the challenges these intentions present and invites others to use them on their paths as healing physicians.
- The core of being able to provide person-centered care lies not "out there" with patients, families, other persons, or even the doctor-patient relationship. Instead, this core lies "within."
The Challenges of Measuring, Improving, and Reporting Quality in Primary Care
Richard A. Young , and colleagues
Background This essay asserts that traditional quality improvement processes used for linear mechanical systems, such as isolated single-disease care, are inappropriate for complex adaptive systems such as primary care.
What This Study Found A new set of priorities for quality management in primary care that better reflects the discipline's complexity and value is needed. Proposed priorities include patient-centered reporting; quality goals not based on rigid targets; metrics that capture avoidance of excessive testing or treatment; attributes of primary care associated with better outcomes and lower costs; less emphasis on patient satisfaction scores; patient-centered outcomes, such as days of avoidable disability; and peer-led qualitative reviews of patterns of care, practice infrastructure, and intrapractice relationships.
Implications
- The authors conclude that the inappropriate application of traditional quality improvement strategies and misaligned metrics undermine primary care and, in turn, all patient care.