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Table of Contents

November/December 2019; Volume 17,Issue 6

The Issue in Brief

The Issue in Brief

Capacity to Address Social Needs Affects Primary Care Clinician Burnout

Alina Kung , and colleagues

Background Twenty-nine primary care clinicians provided insight into the relationship between patient social needs and physician burnout through semi-structured interviews.

What This Study Found Four key themes appeared throughout these interviews: (1) burnout can affect how clinicians evaluate their clinic's social needs resources, (2) unmet social needs affect practices by influencing clinic flow, treatment planning, and clinician emotional wellness; (3) social services embedded in primary care clinics buffer against burnout by increasing efficiency, restoring clinicians' medical roles, and improving morale; and (4) clinicians view clinic-level interventions to address patients' social needs as a necessary but insufficient strategy to address burnout.

Implications

  • The clinicians noted the importance of social needs interventions being timely, accessible, and tailored to each individual patient, while being responsive to patient feedback. The clinicians were skeptical that referral-based interventions based solely on referrals would adequately address patients' social needs.

"It's Like Riding Out the Chaos": Caring for Socially Complex Patients in an Ambulatory Intensive Care Unit (A-ICU)

Brian Chan , and colleagues

Background High-need high-cost (HNHC) patients, many of whom are experiencing poverty, use a large portion of health care resources. Despite receiving more care, such patients often experience poor health outcomes.

What This Study Found Teams providing intensive ambulatory care interventions were interviewed regarding how they view the work of serving socially and medically complex patient populations. Researchers conducted semi-structured, qualitative interviews with nine ambulatory care team members and six "usual care" team members, focused on multidisciplinary staff experiences. Interviews were performed at a Federally Qualified Health Center caring for predominantly homeless HNHC patients in the context of an ongoing implementation of an ambulatory intensive care unit intervention. The staff noted social, behavioral, and medical challenges leading to patient-health care system mismatch. Team members cared for HNHC patients by addressing both psychosocial and clinical needs together; staying connected to patients through chaotic periods; reinforcing commitment and cohesion among interdisciplinary team members; and being flexible enough to create individualized care, tailored to each patient's situation.

Implications

  • Participants more often defined success as improving patient engagement, as opposed to reducing utilization or cost. Flexible approaches for addressing patient-system mismatch appear necessary to address the needs of HNHC patients. Future intervention design may need to account for the high chaos and unpredictable engagement patterns of complex patients

Associations Between Burnout and Practice Organization in Family Physicians

Lars E. Peterson , and colleagues

Background With the rate of burnout as high as 63 percent among family physicians, it is important to identify risk factors for physician burnout.

What This Study Found The relationship between burnout and personal environmental and organizational risk factors was examined in a study of family physicians. A cross-sectional study of 1,437 physicians seeking to continue their American Board of Family Medicine Certification in 2017 was created using data from the examination registration process. Burnout was measured as a positive response to either of two validated questions measuring emotional exhaustion and depersonalization. The study revealed a burnout rate of 43.7 percent; 33.7 percent worked in hospital-owned practices with 65.5 percent having no ownership stake in their practice. Controlling for personal characteristics and practice organization, being in a hospital-owned practice and being a partial owner were positively associated with burnout. When also controlling for practice environment, no practice organization variable remained associated with burnout.

Implications

  • The most important predictors of burnout were practice environment factors such as satisfaction with hours worked, control over workload, value alignment with department leaders, and sufficient time for documentation.

Practice Organization Characteristics Related to Job Satisfaction Among General Practitioners in 11 Countries

Christine Cohidon , and colleagues

Background Organizational and functional features of general practitioner practices in 11 countries were studied in search of underlying reasons for job dissatisfaction.

What This Study Found This was done by conducting a secondary analysis of 12,049 subjects in the 2015 Commonwealth Fund International Health Policy Survey of Primary Care Physicians. Job dissatisfaction was measured on a four-point Likert scale using the question: "How satisfied are you regarding your practicing of medicine?" The findings revealed dissatisfaction at work ranged from 8.1 percent in Norway to 37.4 percent in Germany. Greater dissatisfaction was noted among middle-aged (45 to 54 years old) GPs, those practicing in urban areas and those working alone. Also, high weekly workloads (greater than 50 hours), heavy administrative burdens, long delays in hospital discharge notices (greater than one month), and limited possibilities of offering same-day appointments added to the dissatisfaction.

Implications

  • Using electronic health records and having an in-practice case manager were linked to higher satisfaction. Creating changes such as forming group practices, employing case managers, using electronic health records, and reducing workloads could reduce dissatisfaction levels.

Effectiveness of Community-Links Practitioners in Areas of High Socioeconomic Deprivation

Stewart W. Mercer , and colleagues

Background A common policy response to health inequalities in recent years has been the introduction of different social prescribing programs. However, the evidence base for the effectiveness of social prescribing is extremely limited.

What This Study Found The study assessed the efficacy of a Scottish government-funded program that was developed to target social determinants of health among some of the most socioeconomically vulnerable adults in Glasgow. In the program, "Community-Links Practitioners" connected adult patients with community resources like exercise groups and drug and alcohol management support. The study evaluated the health-related quality of life, at baseline and after nine months, of 288 adults enrolled in the program. The authors compare their scores with 612 non-matched adults in comparison general practices and find no significant benefit in the intervention group. In a subgroup analysis, those who visited the practitioner three or more times showed improved quality of life, but many who enrolled did not fully utilize the program.

Implications

  • The findings of this study call into question the effectiveness of such social prescribing programs for improving short-term health-related quality of life. Discovering ways to improve the uptake and engagement rates of the intervention may lead to better overall outcomes.

The Ecology of Medical Care Before and After the Affordable Care Act: Trends From 2002-2016

Michael E. Johansen , and colleagues

Background At the same time the Affordable Care Act increased the number of insured Americans, analysis of health care industry data shows a continued decline in contact with primary care physician services.

What This Study Found The study applied an "ecology of medical care" framework analysis to a national dataset of Americans� contact with the US medical care system. Tracked services included visits and calls to physicians, including primary care and sub-specialty physicians, emergency departments, inpatient hospitalizations, dental visits and home health visits. Analysis showed a drop in the uninsured rate post-Affordable Care Act, from 12.8 percent in 2013 to 7.6 percent in 2016. Between 2002 and 2016, patients were overall less likely to see a primary care physician, be hospitalized, or receive dental care. However, contact with home health visits increased.

Implications

  • Despite the increase in insurance coverage, the Affordable Care Act appeared to have had minimal effect on the trend of decreasing primary care contact in the general population during the first two years after implementation.

National Trends in Primary Care Visit Use and Practice Capabilities, 2008-2015

Ishani Ganguli , and colleagues

Background Recent evidence shows a national decline in primary care visit rates over the last decade. It is unclear how changes in practice--including the use and content of primary care visits--may have contributed.

What This Study Found Researchers analyzed a weighted sample of 3.6 billion adult primary care visits from 2008 to 2015, collected through physicians surveyed by the National Ambulatory Medical Care Survey. They found primary care visits declined from 336 million to 299 million visits per year, representing a 20 percent decline over the study period. The decline in visits was most pronounced among adults 65 and older, white adults, and those in rural areas. Simultaneously, primary care physicians provided more preventive services and procedures per visit, with more diagnoses addressed and medications prescribed. During the study period, the number of physicians who reported offering secure online messaging increased by 60 percent, with a 44 percent increase in the use of electronic medical records.

Implications

  • The findings offer an optimistic interpretation that the decline in primary care visits per capita may be driven in part by two key improvements in primary care practice, namely, physicians conducting longer, more comprehensive visits and the increased use of non-face-to-face care to address issues outside of in-person visits.

Blue-Light Therapy for Acne Vulgaris: A Systematic Review and Meta-Analysis

Anna Mae Scott , and colleagues

Background Acne is one of the most common reasons for clinical consultations. Market and patient demand is high for light therapy as an alternative to antibiotic approaches to acne treatment. However, conclusions about the effectiveness of blue light therapy for acne are limited.

What This Study Found A new systematic review and meta-analysis of 14 randomized controlled trials of blue light therapy for acne shows methodological and reporting limitations--including small sample sizes, short intervention periods, and variation in reporting quality for acne outcomes. Only three of the trials reported significant improvements in expert-assessed acne severity with blue light therapy over a control group. The majority of trials do not provide sufficient evidence to conclude effectiveness.

Implications

  • Because evidence for blue light therapy is not conclusive, patients should discuss with their clinicians the possible benefits, costs, and alternatives for acne treatment. Blue light therapy may be beneficial for some patients, but more research is needed.

The 3 Cs of Content, Context, and Concepts: A Practical Approach to Recording Unstructured Field Observations

Michael D. Fetters , and colleagues

Background Most primary care researchers lack a practical approach for including field observations in their studies, even though observations can offer important qualitative insights and provide a mechanism for documenting behaviors, events, and unexpected occurrences.

What This Study Found The authors present an overview of qualitative field observations, a research methodology that could be useful to enhance health research projects using primary data collection. The paper illustrates a practical approach to collecting and recording observational data through a "3 Cs" template of content, context, and concepts. To demonstrate how the method can be used routinely in practice, the authors provide an example of a completed template and discuss the analytical approach used during a study on informed consent for research participation in the primary care setting of Qatar.

Implications

  • According to the authors, the 3Cs template, which can be submitted for IRB approval, provides a straightforward mechanism for recording events and behaviors in almost any project involving human subjects.

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