Index by author
The Issue in Brief
Change in Site of Children's Primary Care: A Longitudinal Population-Based Analysis
Richard C. Wasserman , and colleagues
Background Evidence that fewer children are being seen at Family Physician (FP) practices has not been confirmed using population-level data. This study examines the proportion of children seen at FP and pediatrician practices over time and the influence of patient demographics and rurality on this trend.
What This Study Found A Vermont study suggests that a declining proportion of children receive care in family medicine practices. These same children, particularly those in isolated rural areas, are more likely to visit pediatric practices. Using statewide all-payer claims data from 2009-2016, the study looked at 184,794 children with at least two claims in that period. The data revealed that a child's odds of attending a family practice vs. a pediatric practice declined by an average of 5% each year during the study period. Reasons for this trend may include the national decline in family physicians providing prenatal care and lack of capacity for new patients in family medicine practices. The study also showed that the likelihood of attending a family medicine practice went up with increased child age, if the patient was female, or if the patient was enrolled in Medicaid.
Implications
- The declining proportion of children attending FP practices, especially in very rural areas, represents a continuing challenge for the specialty of family medicine.
Patient-Physician Agreement in Reporting and Prioritizing Existing Chronic Conditions
Stephanie Sidorkiewicz , and colleagues
Background Multimorbidity is becoming the norm rather than the exception. Adults with multiple chronic conditions face challenges in navigating complex health care pathways. Their primary care physicians have responsibility for care coordination and prioritization. This study analyzed the level of agreement between patients and their primary care physicians in the identification and prioritizing of the patient's most pressing chronic conditions.
What This Study Found A cross-sectional observational study in France used self-reported questionnaires among 233 patient-physician pairs to identify the patient�s chronic conditions from a list of 124 items and to rank the three most important conditions. Of the 153 pairs that generated priority lists, 29% of patients' first priorities did not appear anywhere on their corresponding physician's list, and 12% of pairs had no matching priority conditions. Furthermore, physicians failed to identify what condition mattered most to patients in 29% of cases. Agreement between patients and physicians varied by condition and were stronger for conditions like hypothyroidism, diabetes, and high blood pressure, and poorer for anxiety and sleep issues.
Implications
- The study was exploratory in nature, yet it points to a need for improved doctor-patient communication in the management of multiple chronic conditions.
Jelle C.L. Himmelreich , and colleagues
Background Performing a traditional electrocardiogram in primary care can be cumbersome and is unavailable in some primary care practices. A new alternativ--a handheld, smartphone-enabled 1-lead EC--may provide physicians with a viable alternative for detecting cardiac arrhythmias in patients presenting with non-acute cardiac concerns in primary care.
What This Study Found This validation study tested the diagnostic accuracy of a smartphone-operated, single-lead ECG (1L-ECG, AliveCor KardiaMobile) with integrated algorithm for atrial fibrillation (AF) against 12-lead ECG in a primary care population. In a multi-center validation study of the device's diagnostic accuracy, blinded cardiologists assessed data from 214 Dutch primary care patients collected simultaneously from the 1L and 12L devices. The handheld device showed excellent diagnostic accuracy, as cardiologists were able to detect all cases of atrial fibrillation and atrial flutter from the device's readings. The study also compared expert review of the handheld device's readings to the smartphone-integrated diagnostic algorithm's interpretation of the device's output. The algorithm correctly identified 87% of atrial fibrillation cases and 98% of non-atrial fibrillation cases. The algorithm was less accurate in categorizing other abnormalities.
Implications
- The findings of this study suggest that the smartphone-operated ECG may be a viable alternative for physicians in need of a point-of-care device to detect key arrhythmias in the preventive care of stroke.
Lennard L. van Wanrooij , and colleagues
Background Primary care physicians rely on a battery of instruments to assess the risk of dementia in older patients. The combination of screening tools must be simple enough to fit within a regular primary care visit, while being comprehensive enough to distinguish patients in need of referral to specialist memory care.
What This Study Found Analysis of data from a longitudinal cluster-randomized controlled trial of 3,526 adults aged 70 to 78 showed that assessment of dementia risk using three common screening tools at baseline predicts incident dementia over the course of about seven years. A single screening question to assess subjective memory loss was associated with future dementia. Furthermore, participants who showed subjective memory loss, who then reached a threshold score on two cognitive function instrument--the Visual Association Test and the delayed recall item of the Mini-Mental State Examination (item 5--showed rates of dementia up to 30% at follow-up. The authors recommend starting with the single question on subjective memory loss, followed by a brief assessment of cognitive delay from the MMSE-5 and then the VAT.
Implications
- The findings of this study suggest that assessing subjective memory loss using a single question chosen from the 15-item Geriatric Depression Scale, in combination with the MMSE delayed recall item and the VAT, may be a promising way to assess dementia risk in primary care.
Potential for Reducing Time to Referral for Colorectal Cancer Patients in Primary Care
Charles W. Helsper , and colleagues
Background Delay in referral to specialty care for patients who have symptoms of colorectal cancer may lead to poor health outcomes. While the current median duration from first consultation with cancer related complaints to referrals is approximately one week for colorectal cancer patients in the UK and the Netherlands, time to referral varies strongly. Some cases document months and even years before referral, and explanations for suboptimal referral is often incomplete or oversimplified.
What This Study Found A retrospective cohort study in the Netherlands reviewed the time to specialty referral for a group of 309 patients with colorectal cancer who initially presented with symptoms to their primary care doctor. A multivariable analysis narrowed down the factors associated with delays in referrals to specialty care. Those who initially presented with red flag symptoms, such as rectal bleeding or unintended weight loss, experienced shorter wait time than those who presented with non-alarming gastrointestinal symptoms. Univariable analysis showed that female patients and patients without a registered family history of the disease were also more likely to have a longer wait period. Of the 10% of patients with the longest wait times for referral to specialty care all patients had received an alternative initial diagnosis from their primary care physicians. These patients usually presented with conditions that obscured concern for colorectal cancer, such as hemorrhoids, fissures and inflammatory bowel disease. Initial diagnoses were not always reconsidered when complaints persisted and follow-up consultations were sometimes omitted.
Implications
- This study points to a relationship between long time to referral of colorectal cancer in primary care and low cancer suspicion. There is potential for reducing longest times to referral of colorectal cancer patients in primary care by earlier reconsideration of the initial hypothesis and implementing strict follow-up consultations.
Professional Communication Networks and Job Satisfaction in Primary Care Clinics
Marlon P. Mundt , and colleagues
Background Much discussion has covered how communication among health care professionals improves the quality of care for primary care patients. However, less insight is available about how communication promotes job satisfaction among health care providers.
What This Study Found Researchers evaluated job satisfaction as it relates to face-to-face communication among staff about patient care. This was performed in a cross-sectional study of 143 physicians and clinical staff from five US primary care clinics. Adjustments were made using factors such as job title, gender, length of time working at the clinic and percentage of full-time employment.
Implications
- Job satisfaction was higher for those more actively engaged in face-to-face communication than those less engaged. Efforts to encourage face-to-face communication among all team members, such as daily team huddles, may improve job satisfaction among primary care physicians and staff.
Interventions Addressing Food Insecurity in Health Care Settings: A Systematic Review
Emilia De Marchis , and colleagues
Background Many health care settings are exploring ways to address social determinants of health, including the reduction of patient food insecurity. Health systems have begun experimenting with providing interventions to address food insecurity as a strategy to improve health; however, the impacts of such interventions on food security, patient health and health behaviors, and health care utilization and cost are unclear.
What This Study Found A systematic review of articles covering food insecurity interventions in health care settings from 2000-2018 found that interventions that included either referrals or direct provision of food or vouchers both suffered from poor follow-up, a general lack of comparison groups, and limited statistical power and generalizability. Of the twenty-three studies included in analysis, 74% were rated low or very low quality. In studies of referral-based interventions, there were moderate increases in process outcomes--like food program referrals (Standardized Mean Differences: 0.67 95% CI 0.36 to 0.98; 1.42 95% CI 0.76 to 2.08) and resource use (pooled SMD: 0.54 95% CI 0.31 to 0.78). In studies of direct food or voucher interventions, outcomes were mixed, with changes in fruit and vegetable intake averaging to no impact when pooled (-0.03 95% CI -0.66 to 0.61). Studies were limited in their evaluation of health or utilization outcomes, with generally small but positive effects.
Implications
- This review revealed limitations in growing literature on health care-based food insecurity interventions. Low quality and lack of studies examining health or health care outcomes limit inferences about their impacts. More rigorous evaluation of food insecurity interventions is needed that includes health and utilization outcomes to better understand roles for the health care sector in addressing food insecurity.
Catherine Hudon , and colleagues
Background Case management for complex patients does not always improve outcomes, but in this systematic review, researchers identified three characteristics of case management programs that consistently yielded positive results.
What This Study Found This review included data from 20 studies, 17 of which were quantitative, of adult frequent users with chronic diseases in primary, secondary and tertiary care settings. Case management was delivered in a primary care setting in all of the studies. Factors such as health care system use, financial cost and patient outcomes were the primary outcomes assessed. All the case management interventions with positive outcomes included some method of identifying a sub-group of frequent users most likely to benefit. The characteristics most commonly leading to positive results included case selection for frequent users with complex problems, high-intensity case management interventions and a multidisciplinary care plan.
Implications
- Most of the methods with positive outcomes included high-intensity case management interventions and care plans developed by multidisciplinary teams. The author suggests that policymakers and clinicians should focus on finding patients most likely to benefit from case management. A high-intensity case management intervention and/or access to a multidisciplinary team may also improve outcomes.