Index by author
The Issue in Brief
Comparing Medical Ecology, Utilization, and Expenditures Between 1996-1997 and 2011-2012
Michael E. Johansen
Background In recent years, US medical expenditures have outpaced inflation and are notably higher than those of other developed countries. This study examines whether increases in expenditures on medical care are related to an increase in the overall number of services used, changes in the types of services provided, and/or the cost or intensity of services delivered.
What This Study Found Between 1996-1997 and 2011-2012, the number of Americans using medical services was unchanged in many categories of service, while expenditures for medical services increased in every category except primary care physicians and home health. Using nationally representative data, the study compared medical ecology (number of individuals using a service), utilization (number of services), and expenditures (dollars spent) in different categories of medical services. It finds that total expenditures increased by 47 percent, from $246 per individual per month in 1996-1997 to $362 per individual per month in 2011-2012, with large increases in dollars spent in every category except primary care physician and home health. The largest absolute increases were in prescribed medications, specialty physicians, emergency department visits, and likely inpatient hospitalizations. A large percentage of the increase (42 percent) related to increases in prescription drug use. In comparison, in 1996-1997, prescribed medications accounted for 12 percent of total expenditures. The number of individuals using medical services was unchanged in many categories of service (total, outpatient, outpatient physician, users of prescribed medications, primary care and specialty physicians, inpatient hospitalization, and emergency department), increased in other categories (optometry/podiatry, therapy, and alternative/complementary medicine) and decreased in dental and home health. The number of services used largely mirrored the findings for individual use, except for an increase in the number of prescribed medications and a decrease in primary care physician visits.
Implications
- Substantially curbing the trend toward higher medical expenditures, the author suggests, will require a greater commitment to working "upstream," at the sources of the challenges facing the US health care system.
Mobility of US Rural Primary Care Physicians During 2000-2014
Matthew R. McGrail , and colleagues
Background Mobility and nonretention of rural physicians has an impact on training, workforce policy, and physician supply in both the location from which the physician moved and the physician's destination area. This study aims to describe the geographic mobility patterns of rural primary care physicians.
What This Study Found Between 2000 and 2014, the mobility rate of younger primary care physicians was approximately double that of older physicians. Biennial turnover of younger physicians was around 17 percent, compared to 9 percent for older physicians, with little difference between rural and metropolitan physicians. Nonretention of physicians was significantly worse in rural counties without a hospital, counties with a smaller population, and those with decreased physician supply. The study, based on AMA Masterfile data, found no association with county-level economic or demographic measures. Female physicians from urban areas were more likely to leave rural practice.
Implications
- The study authors call on rural health workforce planners and policy makers to be cognizant of these key factors in guiding retention policies and support for vulnerable rural communities.
The Effect of Changes in Cervical Cancer Screening Guidelines on Chlamydia Testing
Michelle S. Naimer , and colleagues
Background Screening for chlamydia, the most commonly diagnosed bacterial sexually transmitted infection worldwide, is often conducted with cervical cancer screening. Using population-based physician billing claims data and public health surveillance data, researchers in Ontario, Canada assessed the population-level impacts of new cervical cancer screening guidelines that recommend less frequent screening and older age of screening initiation.
What This Study Found The 2012 cervical cancer screening guideline change is associated with reduced testing for cervical cancer and chlamydia and reduced identification of chlamydia cases in young women. Researchers found that Pap testing declined in all age groups following the guideline release, with the greatest relative reductions observed for females aged 15 to 19 years. The guideline change was also followed by a decrease in chlamydia testing in females aged 15 to 29 years. The largest reduction was observed in the 15- to 19-years age-group, in whom cervical cancer screening is no longer recommended, suggesting that reduced chlamydia testing may have been an unintended consequence of the guideline change. Reduced chlamydia testing coincided with a reduction in reported chlamydia incidence in females aged 15 to 19 years and 20 to 24 years. In contrast, there were small increases in chlamydia testing in males aged 20 to 24 years and 25 to 29 years two years after the guideline change. Incidence rates were unchanged for males.
Implications
- The authors call for separating screening recommendations for sexually transmitted infections from recommendations for cervical cancer and highlight the need to promote chlamydia screening strategies for females that can be adopted into routine clinical care.
Peter Anderson , and colleagues
Background A study spanning four countries (England, the Netherlands, Poland, and Sweden) and the Catalonia region compares three strategies to increase delivery of screening and advice to heavy drinkers: clinician training and support, financial reimbursement, and an option to direct screen-positive patients to an Internet-based method of giving brief advice.
What This Study Found In primary care settings, training and support of clinicians has a lasting effect on the proportion of adult patients given an alcohol intervention at nine months. Researchers find that training and support have a longer-term effect on primary care clinicians' delivery of screening and advice to heavy drinkers as measured by the Alcohol Use Disorders Identification Test�Consumption (AUDIT-C) tool. The study demonstrates a lasting effect of training and support at 9-month follow-up. There was no lasting impact of financial reimbursement.
Implications
- The authors recommend training and support of primary care clinicians in delivering screening and brief advice, repeated over time, in order to increase the volume of brief interventions delivered to heavy drinking patients.
Swimming Against the Tide: Primary Care Physicians� Views on Deprescribing In Everyday Practice
Katharine A. Wallis , and colleagues
Background Safe prescribing entails regular medicines review, initiating medicines that are indicated and deprescribing (tapering and withdrawing medicines) when the risks outweigh the potential benefits. This qualitative study of 24 primary care physicians in Auckland, New Zealand explores the views of primary care physicians on the barriers and facilitators to deprescribing in everyday practice.
What This Study Found Although deprescribing is essential to best prescribing practices, it runs counter to patient expectations, medical culture, and organizational factors. Participants recognized the importance of deprescribing for older patients, while identifying many barriers and few incentives to the practice. Less experienced physicians and those in short-term low-trust therapeutic relationships reported finding deprescribing challenging.
Implications
- The authors state that interventions to support safer prescribing should consider sociocultural influences, the importance to physicians of maintaining relationships, the sense of vulnerability many physicians feel in practice, and the organizational constraints they face.
Proposed Clinical Decision Rules to Diagnose Acute Rhinosinusitis Among Adults in Primary Care
Mark H. Ebell , and colleagues
Background Practice guidelines only recommend the use of antibiotics in patients with prolonged, severe, or worsening symptoms of acute rhinosinusitis (ARS), when the likelihood of a bacterial cause is thought to be higher. However, it is common practice for patients diagnosed with acute rhinosinusitis to be prescribed an antibiotic regardless of the duration of symptoms or their severity. One strategy to reduce inappropriate prescribing is to give physicians tools that can help them more confidently diagnose or rule out acute bacterial rhinosinusitis (ABRS). This study set out to develop a clinical decision rule to diagnose acute rhinosinusitis and acute bacterial rhinosinusitis.
What This Study Found Researchers developed a series of clinical decision rules integrating signs, symptoms, and C-reactive protein that diagnose acute rhinosinusitis and acute bacterial rhinosinusitis with good accuracy. They developed a point score and algorithm for each of 3 reference standards: abnormal CT scan, abnormal antral puncture, or positive bacterial culture. They found that the most appropriate reference standard is positive bacterial culture of antral puncture fluid. The point score using this reference standard successfully identified groups with a low (16 percent), moderate (49 percent) and high (73 percent) likelihood of acute bacterial rhinosinusitis.
Implications
- By identifying patients at low risk for a bacterial infection, this clinical decision rule can lead to more conservative use of antibiotics and help reduce inappropriate antibiotic prescribing.
- According to the authors, prospective validation of the findings and an assessment of their effect on clinical and process outcomes are important next steps.
Julie Dupouy , and colleagues
Background This study investigates mortality in outpatients in France with opioid use disorder treated by buprenorphine, focusing on periods in and out of buprenorphine treatment.
What This Study Found Buprenorphine reduces mortality for those with opioid use disorder, but periods off treatment are associated with much higher mortality rates. The mortality rate for study subjects was 0.63/100 person-year, compared to 0.24/100 person-year for other individuals of the same age range during the same time period.
Implications
- The authors encourage physicians to avoid interruption of treatment and encourage patients to remain in treatment for a sufficient amount of time.
Barriers Rural Physicians Face Prescribing Buprenorphine for Opioid Use Disorder
C. Holly A. Andrilla , and colleagues
Background Opioid use disorder is a significant public health problem. Buprenorphine is an effective office-based medication-assisted treatment, but 60% of rural counties in the US lack a physician with a Drug Enforcement Agency waiver to prescribe it. This study�s purpose was to understand the barriers faced by waivered physicians who do and don't prescribe buprenorphine.
What This Study Found Rural waivered physicians reported a range of concerns about prescribing buprenorphine including medication misuse, time constraints, and lack of available mental health or psychosocial support services. Waivered physicians who don't currently prescribe buprenorphine or have never done so were more likely than current prescribers to report the following barriers: time constraints, lack of patient need, resistance from practice partners, lack of specialty backup for complex problems, lack of confidence in their ability to manage opioid use disorder, concerns about Drug Enforcement Agency intrusions on their practice, and attraction of drug users to their practice. Physicians reporting other barriers described administrative or infrastructure issues (told they cannot do it, don't have the space or staff), regulatory hurdles (including prior authorization and paperwork), difficult patients, and stigma.
Implications
- The study authors call for tailored strategies to address barriers to providing Buprenorphine Maintenance Treatment and to support physicians in adding or maintaining this service.
Challenges for Insured Patients in Accessing Behavioral Health Care
MariaElena Williams , and colleagues
Background A health plan that offers access to clinicians in primary and specialty care is crucial to ensuring access to care.
What This Study Found Researchers found that access to outpatient behavioral health care varies widely; depending on insurance company and level of training, 10 to 59 percent of clinicians can offer a new patient appointment, with psychiatry appointments particularly difficult to schedule. Using a secret shopper method, three researchers made 1,932 calls to behavioral health clinicians affiliated with three major insurance companies. Extrapolating from these findings, the authors estimate that a patient would need to call seven to 10 psychiatrists in order to find an available appointment.
Implications
- Given the stigma and fatigue associated with mental illness, difficulty in obtaining an appointment for behavioral health care is of particular concern.
The Chief Primary Care Medical Officer: Restoring Continuity
Noemi Doohan , and colleagues
Background When patients are admitted to the hospital, their connection to their primary care physician is often disrupted, leading to difficult transitions of care, readmissions, higher costs, and worse health outcomes. In this essay, two family physicians propose a solution.
What This Study Found The authors call for the creation of the hospital chief primary care medical officer. This primary care physician would lead hospital efforts to create systems that ensure the primary care continuum is complete, even for complex patients. The position could be funded by savings that arise from improved value, the authors suggest, particularly as health care systems shift away from a focus on volume towards a focus on value.
Implications
- The authors call for a health care system that supports a trusting primary care relationship at critical junctures in individuals' lives.
Denial: The Greatest Barrier to the Opioid Epidemic
Nicole M. Gastala
What This Study Found When a family physician moved to a new rural community, she was unprepared for the constant flow of patients seeking prescriptions for opioids. In this essay, she recounts her patients� denial and anger and her own feelings of frustration and burnout as she tried to balance good medical care with the wants of her patients. A turning point came when she received training in medication-assisted treatment for opioid addiction. Her role transformed from a "villain" trying to prescribe non-opioid therapies, to a coach. The decision to provide her patients and community with medication-assisted treatment, the author states, led to her professional healing.
- The author calls on health care professionals to challenge their prescribing habits, recognize opioid addiction, and support one another in providing treatment.
Disenfranchised Grief and Physician Burnout
Deborah Lathrop
What This Study Found Physicians regularly encounter losses: not only the death of patients but also more ambiguous losses, including changes in professional roles, duties, and identity. A family physician proposes that these ambiguous losses can cause stress and grief. If not acknowledged and addressed, physicians' grief can both contribute to burnout and be exacerbated by it. The solution, she suggests, is not resilience training for physicians but rather acknowledging their losses and supporting them in addressing their grief.
Cultivating the Inner Life of a Physician Through Written Reflection
Allen F. Shaughnessy , and colleagues
What This Study Found In a medical culture that values technical prowess and the ability to make complex clinical decisions, personal reflection can help physicians cultivate their inner lives, emotions, and spirituality. Residents in a family medicine residency training program were given a protected 15-minute slot in their schedules to write reflections about their experiences with patients. They were not given specific writing prompts and did not submit their reflections for grading or response. Their writings described their struggles and joys in treating patients, goals for the future, and the search for meaning in their experiences.
- A focus on developing inner lives, the authors suggest, allows for the integration of the physician as both a professional and a person.