Table of Contents
The Issue in Brief
Adam W.A. Geraghty , and colleagues
Background Chronic dizziness is commonly seen in US primary care and is often due to vestibular dysfunction (dysfunction in parts of the inner ear and brain that process sensory information involved with controlling balance and eye movements). This study tested the effectiveness of fully automated Internet-based vestibular rehabilitation in improving dizziness symptoms in patients aged 50 and over.
What This Study Found A publicly-available, self-directed Internet-based vestibular rehabilitation program effectively reduces dizziness and dizziness-based disability in older primary care patients without requiring clinical support. The randomized controlled trial involving 296 patients aged 50 years and older with dizziness exacerbated by head movements found that compared with the usual care group, patients in Internet-based rehabilitation group had less dizziness on the Vertigo Symptom Scale-Short Form at three months and six months. Dizziness-related disability was also lower in that group at three months and six months.
Implications
- Given the increasing Internet use being seen in older adults, the authors conclude Internet-based interventions may provide a promising means of greatly increasing the provision of evidence-based self-management strategies for adults in primary care.
Alex H. Krist , and colleagues
Background In this study, researchers examine the potential of health information technology to systematically guide patients through decision making processes for three cancer screening choices. Specifically, the study evaluated how clinicians and patients used an automated decision module that promoted the 2012 prostate, 2009 breast and 2008 colon cancer screening recommendations made by the U.S. Preventive Services Task Force and how that module effected care.
What This Study Found Although automated decision aids have the potential to make office visits more efficient and effective, cultural, workflow and technical changes are needed before widespread implementation. Practices had a large decision burden -- with one in five patients facing a cancer screening decision over the one-year study period. Yet, of the 11,458 patients who faced a screening decision for colorectal cancer, breast cancer or prostate cancer, only 21 percent started and 8 percent completed the decision module. User data showed patients reviewed a range of topics while in the module and 47 percent of the module completers elected to forward a summary to their clinician. After their next office visit, both patients and clinicians reported that module completion helped with decisions: 41 percent said it made their appointment more productive, 48 percent said it helped engage them in the decision, 48 percent said it broadened their knowledge and 38 percent said it improved communication.
Implications
- The authors conclude that while the model is appealing, a clear challenge is getting patients to use such a system. If future research confirms the benefits of this approach -- yielding more informed patients, better decisions and wiser use of encounter time -- the return on investment could offset the implementation costs and improve care.
Patient Perceptions of Telehealth Primary Care Video Visits
Kristin L. Rising , and colleagues
Background Telehealth (or telemedicine) has the potential to increase the flexibility and reach of health services. This study describes patient experiences with video visits with their established primary care clinicians.
What This Study Found Video visits are being adopted in a variety of health care settings, including primary care, because they offer increased care accessibility, decreased transportation barriers and patient empowerment.This qualitative study of 19 adult patients interviewed after video visits with their primary care clinician found that patients accept and even prefer video visits to in-person office visits. Participants reported feeling comfortable talking with their clinicians over a video call, and they identified convenience and decreased costs as benefits. Some patients expressed a preference for receiving future serious news in a video visit citing reasons of comfort, social support and privacy. Primary concerns with video visits concerned privacy, including potential for work colleagues to overhear conversations, and questioning the ability of the clinician to perform an adequate physical examination.
Implications
- The authors conclude these findings add insight into the benefits of video visits in primary care, highlighting improved convenience, efficiency, privacy and comfort for patients. The findings also raise new considerations unique to telehealth that warrant discussion with patients before use, such as using headphones or finding a private room to maintain during video visits outside of the home.
Alignment of Canadian Primary Care With the Patient Medical Home Model: A QUALICO-PC Study
Alan Katz , and colleagues
Background Canada's patient medical home (PMH) model includes ten goals that enable the best possible health outcomes for patients and communities, while emphasizing Canadian health care values. This study aims to determine to what extent the structure and processes that define primary care in Canada align with PMH model goals.
What This Study Found Evaluating the degree to which primary care across Canada comports with the goals of the Patient Medical Home model, researchers find considerable room for improvement. Ten measurable indicators of the PMH model were applied across all 10 Canadian provinces. The results indicated an average national PMH composite score of 5.36 out of 10. Ontario was the only province to score significantly higher than Canada as a whole, while Quebec, Newfoundland/Labrador, and New Brunswick/Prince Edward Island scored below the national average. There was little variation among provinces in achieving the 10 PMH goals. Although the PMH is a pan-Canadian model, implementation is dependent on provincial and regional or local policies, and during the past 15 years, new primary care funding models have been introduced without consistency in timing, key model components or implementation strategies across provinces.
Implications
- The authors call for future research into the effects of reform on practice characteristics and processes, and assessment of health services utilization and quality measures for clinical conditions. The information gained from these activities, they posit, may motivate further uptake of the PMH model's attributes in all provinces
Bridging the Gaps Between Patients and Primary Care in China: A Nationwide Representative Survey
William C.W. Wong , and colleagues
Background China's commitment to develop a strong primary care system through the establishment of community health centers has succeeded in creating more than 8,600 centers. However, there is a lack of trust in the newly-revamped system. This study examines the current quality of community health centers in China.
What This Study Found China's community health centers are underused in part because of public mistrust of the physicians and because few centers are equipped to provide comprehensive primary care for a wide range of common physical and mental conditions. A survey of the structure and organization of the Chinese primary care system found less than one-half of physicians employed by CHCs were registered as primary care practitioners and few nurses had training specifically for primary care. Clinics were equipped with basic primary care equipment such as stethoscopes and sphygmomanometers, but only 43 percent had opthalmoscopes and 64 percent had facilities for gynecologic examination. Most CHCs had inpatient beds for their patients; however, only 38 percent had microbiology support and only 53 percent offered Pap screening. Clinical care was selectively skewed toward certain diseases. Virtually all CHCs provided management of common ailments, chronic diseases, hypertension, diabetes, traditional Chinese medicine, maternal and infant health care, and vaccinations, however large proportions did not provide management for other common conditions such as dyslipidemia, mental illness, sexually transmitted infections, and chronic obstructive pulmonary disease. Use of services by patients was poor at each CHC: despite serving 50,000 people, the centers had an average of only 41,000 patient contacts a year, and each physician saw a median of only 12.5 patients per day.
Implications
- Based on these findings, the authors conclude that Chinese policy makers need to reconceptualize health care training and policy in order to alter the public perception of primary care in the country. There is a need, they write, to develop tools to evaluate primary care activities more clearly, integrate community-oriented thinking into primary care, and teach an integrated comprehensive approach (such as multidisciplinary teams), rather than selected care with a purely biomedical approach.
Premature Death Among Primary Care Patients With a History of Self-Harm
Matthew J. Carr , and colleagues
Background Self-harm is a major public health problem. This study investigates risk of dying prematurely from any cause after self-harm.
What This Study Found Primary care patients who have harmed themselves are at greatly increased risk of dying prematurely by natural and unnatural causes, especially within a year of a self-harm episode. Among 30,017 patients aged 15 to 64 years, there was an elevated risk of dying prematurely from any cause among the self-harm group, especially in the first year of follow-up. In particular, suicide risk was especially high in the first year. Although it declined sharply after one year, it remained much higher than in the comparison group. During the 10-year follow-up period there were also large increases in risk for accidental, alcohol-related and drug-poisoning deaths.
Implications
- The authors point out that patients with a history of self-harm visit clinicians at a relatively high frequency, which presents a clear opportunity for preventive action. They call for national guidelines that provide more specific recommendations and training on how primary care teams can more effectively intervene, manage, and monitor risk in these patients.
Impact of Gaps in Merit-Based Incentive Payment System Measures on Marginalized Populations
Kyle Eggleton , and colleagues
Background Although pay-for-performance programs can lead to overall improvements in health outcomes, they may unintentionally worsen health disparities for marginalized populations. This study examines Medicare's Merit Based Incentive Payment System (MIPS) to determine if gaps exist with a focus on health disparities.
What This Study Found There are gaps related to measurement of access, patient experience, and interpersonal care, raising concerns that MIPS may fail to measure the broader aspects of health care quality and even risk worsening existing health disparities. A total of 143 of 270 MIPS measures applied to primary care, and most were related to aspects of clinical experience; most of the domains that reflected quality of primary care were not represented. Five of 12 domains had no applicable measures, and only 10 percent of the measures fell into another five domains of primary care.
Implications
- The authors conclude that for MIPS and similar pay-for-performance programs to have a positive effect on health outcomes for marginalized populations, policy makers should apply a theoretical framework to the measures in order to ensure the broad domains of quality, equality in particular, are included. Doing so, they assert, can help identify gaps and develop measures that incentivize addressing health disparities. In failing to do so, they warn, pay-for-performance measures may not achieve their goals of
A Hepatitis C Treatment Program Based in a Safety-Net Hospital Patient-Centered Medical Home
Karen E. Lasser , and colleagues
Background Hepatitis C virus (HCV) is a growing public health problem, causing 15,000 deaths annually in the United States. New oral treatment regimens have opened up the possibility of treatment in the primary care setting, but models for doing so are lacking.
What This Study Found Researchers in Boston describe a successful HCV treatment program embedded in an urban, safety-net hospital. The program utilizes a multidisciplinary approach with primary care and public health social workers working together to facilitate patient engagement and provide treatment. Funding support was also novel, coming from revenue from the 340b drug discount program, which allows clinicians to generate revenue when patients fill prescriptions at pharmacies in safety-net settings, as insurance reimbursements for medications exceed the cost at which safety-net clinicians purchase medications. Over the course of one year, the program received 302 referrals, approximately 23 percent of whom have received treatment.
Sonia Conejo-Ceron , and colleagues
Background With major depressive disorder projected to become the single leading cause of global disease burden in high-income countries by 2030, there is increased interest in preventing depression. Primary care is an ideal setting in which to undertake disease prevention strategies for depression, yet little is known about the effectiveness of psychological and educational interventions to prevent depression in primary care.
What This Study Found This systematic review of 14 randomized controlled trials involving 7,365 patients examined the effects of interventions to prevent depression in nondepressed patients. There was a modest but positive effect of psychological and/or educational interventions to prevent depression in primary care. Based on these findings, the authors conclude the incidence of new episodes of depression could be reduced on average by 26 percent if primary care managers and physicians were to implement programs and interventions to prevent depression.
Implications
- The authors call for further RCTs to determine which programs and interventions are most efficient in primary care.
Finding Hope in the Face-to-Face
Jennifer Y.C. Edgoose , and colleagues
Background This essay explores possibilities for generating hope through a low-tech means: the face-to-face encounter. Using a framework developed by the French philosopher and Holocaust survivor Emmanuel Levinas (1906-1995), the authors explore the unique responsibility and potential for hope found only in face to face encounters. They write that, although face-to-face encounters are at the heart of the patient-clinician relationship, their singular significance is often lost amid the demands of today's high-tech, metric-driven health care systems. They conclude that revisiting this most fundamental attribute of medicine is likely clinicians' greatest chance to reclaim who they are and why they do what they do.