Table of Contents

The Issue in Brief

Higher Primary Care Physician Continuity is Associated With Lower Costs and Hospitalizations

Andrew Bazemore , and colleagues

Background Although continuity of care is a defining characteristic of primary care associated with lower costs and improved health equity and care quality, there has been little research of continuity as a quality measure linked to policy-relevant outcomes. This study examines the relationship between physician-level continuity and health care expenditures and hospitalizations.

What This Study Found An ongoing patient-physician relationship is strongly associated with lower total health care costs and decreased hospitalization rates. Based on 2011 Medicare claims data for 1,448,952 beneficiaries receiving care from a nationally representative sample of 6,551 primary care physicians, researchers created physician-level claims-based measures of continuity of care utilizing four established methods. When tested, all four continuity measures were strongly correlated with health care expenditures and hospitalizations. Of the beneficiaries obtaining some care from primary care physicians in the sample, 1,178,369 (81 percent) obtained most of their care from these physicians. In analyses of one of the established continuity measures (the Bice-Boxerman Continuity of Care Index), adjusted expenditures for beneficiaries cared for by physicians in the highest continuity quintile were $6,920, 15 percent lower than those in the lowest quintile ($7,664). The odds of any hospitalization were 16 percent lower for those with the greatest continuity compared to the lowest levels.

Implications

• This study contributes to the overwhelming evidence of the value of continuity care, the authors suggest, and offers quality measures that can be used and prioritized in value-based payment models.
• As the American health care system shifts from paying for services to paying for value, continuity of care is one of several core tenets of primary care that should be incorporated into official primary care measures, according to the authors.

From Good to Great: The Role of Performance Coaching in Enhancing Tobacco-Dependence Treatment Rates

Sophia Papadakis , and colleagues

Background This study examines the effect of 'performance coaching' as part of a multi-component approach to increasing rates of treatment for tobacco dependence by primary care clinicians.

What This Study Found Integrating 'performance coaching' into the design and delivery of multi-component tobacco treatment interventions significantly increases rates of tobacco dependence treatment by primary care clinicians. In a cluster-randomized controlled trial, 15 primary care practices, including 166 primary care clinicians and 1,990 patients, were randomly assigned to one of two interventions. Both interventions helped teams implement the 5As model of treating tobacco use (Ask, Advise, Assess, Assist and Arrange) in the context of 10 best practices for delivering tobacco treatment. One intervention group also provided a 1.5-hour coaching session and an individualized performance report for family physicians and nurse practitioners. Both groups increased rates of tobacco dependence treatment delivery, however clinicians who received performance coaching had statistically higher rates of providing three elements of the 5 As: asking patients about their smoking status, assisting patients ready to quit by developing a quit plan, and arranging follow-up support. In sensitivity analysis, rates of tobacco cessation advice were greater among clinicians who attended a coaching session. There were no differences in tobacco cessation outcomes between the two groups.

Implications

• According to the authors, this study supports the integration of performance coaching into multi-component interventions to further increase the delivery of tobacco treatment, particularly among low-performing clinicians.

Prenatal Point-of-Care Tobacco Screening and Clinical Relationships

Katherine J. Gold , and colleagues

Background Up to one-third of female smokers with Medicaid deny tobacco use during pregnancy. Point-of-care urine tests can help to identify women who may benefit from cessation counseling. This study evaluates patient and clinician perspectives about using such tests during prenatal care to identify smokers, with particular focus on the impact of testing on clinical relationships and the potential for stopping smoking.

What This Study Found This study finds that, despite reservations, low-income patients have a favorable view of using urine testing, with consent, to promote smoking cessation during pregnancy. The study included 19 individual interviews and four focus groups with a total of 40 pregnant or postpartum women with Medicaid who smoked before or during pregnancy and 20 interviews with clinicians. Researchers collected patient urine samples using a test strip system which provides semi-quantitative detection of cotinine, a major nicotine byproduct. The majority of women interviewed (89 percent) strongly supported testing for tobacco use in pregnancy, but some feared the consequences of positive cotinine test results. Specifically, they were concerned about their clinician's reaction, potential violation of their privacy, and the involvement of government entities such as Child Protection Services. Women reported they would be more open to testing if clinicians described how the test could help them and their pregnancies. The majority of clinicians (more than 80 percent), were concerned that urine testing would have a negative impact on their relationship with patients.

Implications

• The authors call for research into the feasibility of consensual urine testing for tobacco use in the clinical setting. If increased testing leads to more patients getting support and counseling for tobacco cessation, they state, the benefits to public health could be enormous.

Legacy Drug-Prescribing Patterns in Primary Care

Dee Mangin , and colleagues

Background Inappropriate prescribing of medications is often thought of in terms of the number, types or combinations of drugs prescribed at the same time, but it can also be considered in terms of the duration of prescriptions. This study evaluates the proportion of "legacy prescribing" (medications that are not appropriately discontinued when their usefulness has diminished) and when the risk of side-effects, interactions with other drugs, and ongoing costs remain) within 3 drug classes and associated patient characteristics.

What This Study Found The continuation of drugs that are not intended to be taken indefinitely is a substantial and common problem that could contribute to over-medication, particularly in the elderly. In (n = 50,813). The study of adults in and around Hamilton, Ontario, Canada calculated rates of legacy prescribing for three types of drugs: antidepressants (continuous prescribing of more than 15 months), bisphosphonates (continuous prescribing of more than 5.5 years), and proton pump inhibitors (continuous prescribing of more than15 months). The proportion of patients having a legacy prescription at some time during the study period was 46 percent (3,766 of 8,119) for antidepressants, 14 percent (228 of 1,592) for bisphosphonates, and 45 percent (2,885 of 6,414) for proton pump inhibitors.

Implications

• The authors point out that prescribing systems are largely geared towards starting and continuing medicines; most have no controls to flag the end of an intermediate-term prescription, while routine re-prescribing systems and software features are common. These results are therefore not surprising and indicate a need for system-oriented change that encompasses prescribing systems, education and patient-pharmacist-physician communication on appropriate stopping of drug therapy.
• The authors also suggest that legacy prescribing could be explored as a quality measure to incentivize restraint in a system where there are currently few, if any, indicators of the adverse effects of too much medicine.

Clinic-Based Patellar Mobilization Therapy for Knee Osteoarthritis: A Randomized Clinical Trial

Regina Wing Shan Sit , and colleagues

Background Knee osteoarthritis is a major cause of pain and disability. Clinical guidelines recommend using non-pharmacological strategies as first-line treatment for knee osteoarthritis, but few clinical trials have evaluated manual therapy and exercise. This study evaluates a simple clinic-based mobilization therapy for the patella (kneecap) applicable in primary care settings.

What This Study Found An intervention combining passive joint mobilization to realign the patellar (kneecap) position, along with exercise to maintain it, can reduce pain and improve function and quality in life in patients with knee osteoarthritis. In a randomized clinical trial, 208 primary care patients with knee osteoarthritis were assigned to either a patella mobilization therapy intervention group or a waiting list (control) group. In the intervention group, physicians mobilized the patellofemoral joint (the joint formed by the kneecap and femur) once every 2 months during three treatment sessions. Patients were placed in a side-lying position with the knee supported and slightly flexed to allow a vertical gravitational glide of the patella from a lateral to medial direction. Physicians also prescribed twice-daily home exercise to encourage continuous firing of the muscle and supervised patients to ensure that they performed the exercises correctly. The waiting list group received patella mobilization therapy after the study period. At 24 weeks, patients in the intervention group demonstrated significantly greater improvement in pain score than those in the waiting list group. Unlike conventional mobilization therapy involving multiple treatment sessions at intense frequency, this technique can easily be performed in primary care practice. The approximate time needed to learn and practice patella mobilization therapy is about one hour. Patient compliance with the study was high, suggesting that it is an acceptable treatment option.

Implications

• Next steps, the authors state, are to compare patella mobilization therapy with other active controls to further confirm its benefits and facilitate its deployment in real-world practice.

Older Adults' Preferences for Discussing Long-Term Life Expectancy: Results From a National Survey

Nancy Li Schoenborn , and colleagues

Background Clinical practice guidelines recommend incorporating long-term life expectancy to inform a number of decisions in primary care. We aimed to examine older adults' preferences for discussing life expectancy in a national sample.

What This Study Found A majority of older adults do not wish to discuss life expectancy when presented with a hypothetical scenario on the topic. In a survey of communication around life expectancy, 878 adults age 65 years and older received a description of a hypothetical patient with limited life expectancy who is not imminently dying. Participants were asked, as the hypothetical patient, if they would like to talk with the doctor about how long they might live, if it was acceptable for the doctor to offer such discussion, whether they would want the doctor to discuss life expectancy with family or friends, and when life expectancy should be discussed. Fifty-nine percent of participants (n = 515) did not want to discuss how long they might live in the presented scenario. Among these, 291 participants did not think that the doctor should offer discussion, and 450 participants did not want the doctor to discuss life expectancy with family or friends. As estimated life expectancy increased, fewer participants felt that it should be discussed. Fifty-six percent of participants (n = 478) only wanted to discuss life expectancy if it were less than two years. Factors associated with wanting to discuss life expectancy included higher educational levels, belief that doctors can predict life expectancy, and past experiences with either a life-threatening illness or with discussing life expectancy of a loved one. Reporting that religion is important was associated with lower odds of choosing to discuss life expectancy.

Implications

• Overall, this research--the first national study to examine these questions�-found that long-term life expectancy can be an important factor in health care decisions for older adults, but whether, when, and how to communicate with patients about it is not clear.
• The authors suggest that strategies to address this topic include assessing patient factors associated with willingness to discuss life expectancy and offering the discussion when closer to the patient's final year of life.

Factors Associated With Loss of Usual Source of Care Among Older Adults

Stephanie K. Nothelle , and colleagues

Background Access to a usual source of medical care is particularly important for older adults as they manage chronic medical conditions. Although most older adults have a usual source of care, loss of that source of care and associated factors have not previously been examined.

What This Study Found According to this national study, odds of losing a usual source of care are higher among older adults who have unmet transportation needs, who move to a new residence, or who report symptoms of depression. Odds of losing a usual source of care are lower for older adults with four or more chronic conditions and with supplemental or Medicaid insurance coverage. The study followed 7,609 participants in the National Health and Aging Trends Study, a nationally representative sample of Medicare beneficiaries age 65 years and older, for up to six years (2011-2016). Of the 95 percent of older adults who reported having a usual source of care in 2011, five percent subsequently did not. Most participants (60 percent) who reported loss of a usual source of care regained it by the next round of the study, however, those who did not regain it were more likely to continue to report lack of a usual source of care. The study results suggest that clinical as well as social factors are important in an older adult's ability to maintain a stable relationship with a clinician over time.

Implications

• The authors call for future work to assess how changes in health insurance, transportation and residence affect older adults' ability to experience a continuous source of care and the impact of that continuity on functional decline and hospital admissions.

Panel Size, Clinician Time in Clinic, and Access to Appointments

David Margolius , and colleagues

Background With a worsening shortage of primary care clinicians, the availability of follow-up appointments could become more scarce. This study investigates if wait time for appointments is associated with panel sizes (the number of patients under a clinician's care) or the number of half-days primary care clinicians work.

What This Study Found Part-time clinicians may be less able to offer timely appointments to their patients than their full-time counterparts. Researchers examined the relationship between appointment backlog, panel size, and clinician time in clinic. Among 114 primary care clinicians, less clinician time in clinic was independently associated with longer backlogs for appointments. Panel size, without adjusting for full-time equivalency and number of clinicians per site, had almost no correlation with access.

Implications

• These findings are particularly important in light of the increasing rate of clinicians who work part-time.
• The authors suggest that primary care practices consider, (1) establishing clinician teams to co-manage a patient panel and deliver more timely access to appointments, (2) establishing teams of clinicians and non-clinicians to reduce the need for traditional face-to-face clinician visits, and (3) reducing panel sizes which, the authors suggest, may be less feasible and perhaps less important than the presence of a clinician in the practice.

Access to Primary Care for Persons Recently Released From Prison

Ruth Elwood Martin , and colleagues

Background People who have been in prison have high rates of illness and death, particularly at the time of release from prison. In the United States, lack of health insurance is a significant barrier to primary care access after release from prison, but this should not be a barrier in Canada, which has a universal health care system. This study sets out to determine whether a history of recent release from prison affects access to primary care in Canada.

What This Study Found A history of recent imprisonment can affect an individual's access to primary care in Canada. Researchers phoned to request an initial appointment with all family physicians in British Columbia, Canada accepting new patients (n = 339). Participants were assigned patient scenarios: male or female recently released from prison and male or female control group. Those who presented as having recently been released from prison were significantly less likely than controls to be offered an initial appointment with a primary care physician. The likelihood of obtaining an appointment was almost two times greater for controls compared to those who reported a recent prison history; 43 percent of those reporting recent release from prison obtained an appointment compared to 84 percent of controls. There was no difference in the likelihood of obtaining an appointment between male and female callers who reported recent release.

Implications

• Even in the context of a universal health care system, recent imprisonment may be a barrier to access to primary care, the authors state. They call for policies and programs to support people in gaining access to health care during the challenging transition from prison to the community.

Clinical interpretation of Peripheral Pulse Oximeters Labeled "Not for Medical Use"

Arlene J. Hudson , and colleagues

Background This study clarifies limitations of off-label use for low-cost non-medical use pulse oximeters, devices widely used to measure oxygen saturation, by primary care clinicians. These devices are widely marketed over the Internet and in drugstores, but are not intended for medical use or reviewed by the US Food and Drug Administration.

What This Study Found In patients with oxygen saturation at or above 90 percent, peripheral pulse oximeters have similar readings regardless of whether they are approved for medical use. The study of oxygen saturation compared patients using one pulse oximeter approved for medical use by the Food and Drug Administration with eight devices labeled "Not for Medical Use" and not FDA reviewed. Nineteen women and 41 men were studied and 669 data points (69-104 per oximeter) were obtained. There was no meaningful difference in displayed oxygen saturations between medical use and non-medical use pulse oximeters in the range from 90-99 percent.

Implications

• Non-medical use pulse oximeters, the authors suggest, may be able to rule out hypoxemia, an abnormally low concentration of oxygen in the blood, in clinical settings.
• Because pulse oximeter measurements of oxygen saturation are less accurate below 90 percent, however, patient management decisions regarding oxygenation should be verified using a device intended for medical use whenever possible

Primary Care Clinicians' Willingness to Care for Transgender Patients

Deirdre A. Shires , and colleagues

Background Transgender patients report negative experiences in health care settings, but little is known about clinicians' willingness to care for them. This study surveyed primary care clinicians in an integrated Midwest health system.

What This Study Found Most, but not all, family medicine and general internal medicine clinicians are willing to provide routine care for transgender patients. The survey of 308 primary care clinicians found that 86 percent of respondents (n = 140) were willing to provide routine care to transgender patients and 79 percent were willing to provide Pap tests to transgender men. Willingness to provide routine care decreased with age. Willingness to provide Pap tests was higher among family physicians, those who had met a transgender person, and those who measured lower on a transphobia scale.

Implications

• These findings, according to the authors, underscore the importance of integrating personal exposure to transgender individuals into medical education.

Communicating With Patients Who Have Nonbinary Gender Identities

Alex S. Keuroghlian , and colleagues

Background The increasing visibility of transgender people and others who do not conform to traditional gender norms challenges medical professionals to think about gender and communication in new ways. An essay from the National LGBT Health Education Center illustrates ways to interact respectfully and affirmatively with non-binary people (those who have a gender identity that is not exclusively girl/woman or boy/man) throughout the patient care experience.

What This Study Found A small but growing body of research indicates that non-binary people experience high levels of societal victimization and discrimination and are misunderstood by clinicians. Using language that is inclusive of all gender identities can reduce these burdens and barriers, the authors suggest. This includes avoiding assumptions about patients' gender identities, asking for information about name and pronouns, and using these consistently throughout the clinical setting, and describing anatomy and related terms with gender-inclusive language. These communication approaches, according to the essay, can help clinicians offer patient-centered care that moves beyond binary gender concepts.

The Gift of Empanelment in a "Clinic First" Residency

Kumara Raja Sundar

Background In a traditional family medicine residency, residents often rotate monthly from one clinical service to another in block rotations to build skills in different disciplines, including outpatient clinical skills. Outside of an outpatient skills block, resident time in clinic is often limited to one half-day per week. In this essay, a family medicine resident makes a case for structuring primary care training around a "clinic first" curriculum where providing excellent outpatient clinical care and understanding the value of relationships "are the cornerstone of our learning."

What This Study Found The author describes a model in which residents are consistently present in clinic and empaneled with approximately 400 patients each that they care for from the beginning of their residency. Empanelment, the author states, has "allowed me to not only provide comprehensive care to my patients but also allowed me to develop competency and proficiency in managing their acute and chronic illnesses." Providing ongoing care has also helped him build relationships and understand the value of primary care. Residents need this type of experience, he states, in order "to build the primary care workforce of the future."