Table of Contents
The Issue in Brief
Cancer Survivorship Care Roles for Primary Care Physicians
Jenna Howard and colleagues
Background Primary care physicians are treating an increasing number of cancer survivors, yet they have no clear guidance on how best to care for such patients. This study considers how primary care physicians perceive their role in delivering care to cancer survivors.
What This Study Found Researchers conducted interviews with 38 primary care clinicians and collected data on the 14 practices in which they worked. While most felt cancer survivor care was within their purview, their approaches toward treating cancer survivors varied widely. More broadly, this study brings into question the role of primary care in addressing the complex needs of cancer survivors.
Implications
- The researchers recommend coordinating care between primary care physicians and oncologists as patients transition to long-term survivorship.
Joy Melnikow and colleagues
Background The expansion of Medi-Cal, California's Medicaid program, gave millions of low-income Californians access to health insurance. When new Medi-Cal enrollees have trouble getting a doctor's appointment, it is not uncommon for them to visit emergency rooms if they require more immediate care.
What This Study Found A study conducted in Northern California found that new patients may have to wait up to a month for an appointment with a participating primary care clinician, depending on their county of residence.This study looks at the variation between contiguous counties in the availability of new patient primary care appointments for Medi-Cal enrollees and at the correlation between primary care access and rates of Medi-Cal patients' emergency room usage. Researchers found that counties where it was more difficult to schedule new patient primary care appointments had higher rates of emergency room usage by Medi-Cal patients. Emergency room visits for concerns that would ordinarily be treated by primary care practitioners place a greater strain on already overburdened emergency departments and drive up health care costs overall. According to the study's authors, the data suggest that "adequate access to primary care will begin to improve health outcomes and control costs among beneficiaries of Medicaid expansion." Further studies would be needed to determine how California's challenges compare with those faced by other states that have expanded Medicaid eligibility under the Affordable Care Act.
Implications
Case Management in Primary Care for Frequent Users of Health Care Services: A Realist Synthesis
Catherine Hudon and colleagues
Background Case management (CM) is an effective, collaborative, and cost-effective way to help frequent users of health care services integrate all aspects of their care. The research team behind this study developed a program theory to investigate how, and in what circumstances, case management in primary care works to improve outcomes among frequent users who have chronic conditions.
What This Study Found Starting with a broad systematic review of the CM literature, the team clarified the purpose of their review at each step; in turn, they were able to articulate increasingly more refined iterations of their theory as their key questions took shape. They shifted their primary focus from CM resources at the start of their survey toward identifying patients' and clinicians' participation as essential elements of CM's success. Ultimately, they were able to uncover contextual factors and triggers that lead to positive patient and system-level outcomes of CM in primary care for frequent users with chronic conditions. CM tends to be successful when both patients and clinicians feel supported, respected, accepted, engaged, and committed; and when patients feel less anxious, more secure, and empowered to self-manage.
Implications
- The authors of the study conclude that "the objective of CM should be to enable an experienced and accessible case manager, a comprehensive approach to patient care, and positive interactions throughout the health care process. This will trigger the development of a trusting relationship that fosters both patient and clinician engagement and will lead to improved patient and clinician experiences, better patient health outcomes, and decreased health care system costs."
- The study only looks at case management in primary care for frequent users of health care, rather than case management use more generally. Additionally, further research is required to examine whether the care setting or the professional role of case managers, such as nurses and social workers, may have an influence on the development of the patient-case manager relationship.
Primary Care Practice Transformation Introduces Different Staff Roles
Kaylyn E. Swankoski and colleagues
Background The Comprehensive Primary Care initiative was launched in 2012 by the CMS Innovation Center as a four-year multi-payer initiative designed to strengthen primary care.
What This Study Found This study examines shifts in staffing patterns, from 2012 to 2016, at 461 primary care practices participating in the CPC transformation initiative with those at 358 non-CPC practices. Over the course of the study, CPC practices moved away from a traditional staffing model of physicians with medical assistants as they added a variety of new staff, most commonly care managers or coordinators and behavioral health staff, to support patients with comprehensive, team-based care. Non-CPC practices, by comparison, did not increase their diversity as much as CPC practices did. For example, in 2016, 84% of CPC practices had care managers or care coordinators, but only 36% of comparison practices had them.
Implications
- The authors suggest that future studies should: * Examine the effect of team-based care and staff composition on health care cost, service utilization, patient experience and the overall sustainability of new staffing models.
- * Address how practices make decisions about augmenting staff in response to patients' medical and social needs.
Regina Wing Shan Sit and colleagues
Background Primary care clinicians treat many patients for knee osteoarthritis (KOA), a chronic and painful degenerative condition. Conservative treatment options such as physical therapy and anti-inflammatory drugs often prove minimally effective; knee replacement is costly and, as with any surgery, carries some risks. One option in the middle of this spectrum, intra-articular injections of hypertonic dextrose, is a procedure which can be performed in a primary care setting. The purpose of this study was to test the efficacy of this treatment.
What This Study Found A randomized controlled trial conducted by a research team at a primary care clinic at the Chinese University of Hong Kong indicates that intra-articular-only injection therapy with hypertonic dextrose is safe and effective for alleviating symptoms of knee osteoarthritis. Over 52 weeks of treatment, the study followed 76 patients who were between 45 and 75 years old who had been diagnosed with knee osteoarthritis and who suffered moderate to severe chronic knee pain for at least three months. One group of 38 patients received the hypertonic dextrose injection therapy, while the other had the same therapy only using normal saline. While both groups reported some improvement, the hypertonic dextrose group reported more significant reductions in pain by the conclusion of the study.
Implications
- Intra-articular dextrose prolotherapy injections reduced pain, improved function and quality of life in patients with KOA compared with blinded saline injections.
- The procedure is straightforward and safe. It may be appropriate for patients whose KOA has not responded to more conservative treatment.
Results of Lung Cancer Screening in the Community
John R. Handy, Jr and colleagues
Background The benefits of routine lung cancer screenings have been hotly debated in the medical community. After reviewing a national trial published in 2011, the US Preventive Services Task Force introduced a recommendation for systematic low-dose CT lung cancer screenings for people at high risk. At the time, some leaders in the primary care community were not convinced that there was strong enough evidence in the initial trial to support routine screening. The current cohort study evaluated a lung cancer screening program within a large metropolitan non-university, non-NLST, community, tertiary care system.
What This Study Found The new lung cancer screening cohort study (n = 3,402) conducted at a large integrated health system suggests that lung cancer screening in primary care is feasible. The study demonstrated low adverse event rates, and 70 percent of diagnosed lung cancer cases were detected at early stages in their development. Ninety-five lung cancers were diagnosed: 84 non-small cell (stage 1: 60; stage 2: 7; stage 3: 9; stage 4: 8), and 11 small cell lung cancers. The procedural adverse event rate was 23/226 (10.1%) in 21 patients (0.6% of all screened individuals). Pneumothorax (n= 10) was the most frequent, 6 requiring pleural drainage. There were 2 deaths among 85 surgeries or 2.3% surgical mortality.
Implications
- Our LCS experience in a community setting demonstrated lung cancer diagnosis, stage shift, intervention frequency, and adverse event rate similar to the NLST. This study confirms that LCS can be performed successfully, safely, and with equivalence to the NLST in a community health care setting.
Artificial Intelligence and Primary Care Research: A Scoping Review
Jacqueline K. Kueper and colleagues
Background Artificial intelligence methods are being utilized in radiology, cardiology and other medical specialty fields to quickly and accurately process large quantities of health data to improve the diagnostic and treatment power of health care teams. Compared to other medical specialty fields, primary care physicians deal with a very broad spectrum of illnesses, taking a person-centric approach to care, with fewer diagnostic instruments or tests available. The nature of primary care may pose unique challenges to the meaningful application of AI.
What This Study Found A comprehensive review of 405 studies led by researchers at Western University in Ontario shows that work on AI for primary care is at an early stage of maturity. The scoping review summarizes major trends in primary care AI.
Implications
- "For the field to mature," the authors note, "value must be placed both on developing rigorous AI and on identifying potential impacts...on care delivery and longer-term health outcomes."
COVID-19: Notes From the Front Line, Singapore's Primary Health Care Perspective
Wei Han Lim and Wei Mon Wong
Background Singapore, a global hub for international travel and business, was among the first countries affected by the COVID-19 pandemic. With its first confirmed COVID-19 case on January 23, 2020, the country mounted aggressive public health and containment measures. The country's network of primary care clinics were at the front lines of these measures.
What This Study Found In this new report, those physicians share their triage, containment and infection control measure--including protocols they put in place to ensure the safety of health care workers. At the time of writing the report, zero health care workers within their primary care network were infected with COVID-19. The authors describe the framework for how their primary care clinics responded to this pandemic in the hope others may find solutions to their unique needs.
Physician Involvement in Promoting Gun Safety
Amy Lynn McGuire and colleagues
Background As strategies to curb gun violence at the federal level have stalled, leaders in primary care and health policy have identified the role doctors can play in national gun safety efforts and the prevention of firearm suicide.
What This Study Found Amy Lynn McGuire and colleagues at the Baylor College of Medicine and the Center for Medical Ethics and Health Policy, identify barriers that doctors face in addressing the issue of gun safety and violence with patients. State-level legislation has attempted to prohibit physicians from inquiring about a patient's firearm ownership, resulting in long lasting fears of a "gag order" heightening physicians' concerns over potential liability. Additionally, physicians may be concerned that discussing firearm safety could break the trust they establish in the doctor-patient relationship.
Implications
- The authors advocate that discussions about gun safety and violence become a standard component of routine clinical care to step up the effort to protect public safety and improve public health.
The Firearm Suicide Crisis: Physicians Can Make a Difference
Thomas M. Wickizer and colleagues
Background As strategies to curb gun violence at the federal level have stalled, leaders in primary care and health policy have identified the role doctors can play in national gun safety efforts and the prevention of firearm suicide.
What This Study Found Thomas M. Wickizer and colleagues at the Ohio State University focus on the issue of firearm suicide and how improvements in primary care health screening could enhance physicians' ability to identify patients most at risk. Adding firearm safety questions to mental health screening could make firearm safety a more routine part of primary care. The authors also call on collective advocacy for policy change, recognizing the role that physician organizations have historically played in bringing about state-level drunk driving laws and regulation of tobacco advertising. In the wake of gun violence tragedies, physicians have mobilized on social media, using #ThisIsOurLane. The authors believe the medical community can harness the momentum of their online conversations to collectively influence the political discourse on firearms.
Physical Distancing With Social Connectedness
Kurt C. Stange and colleagues
Background Relationships between patients and clinicians matter, even in telehealth visits. A new article explores how clinicians can invest in relationships during a variety of visit types, from short-term telehealth, urgent care, and emergency department visits to ongoing visits for well care and chronic disease management.
What This Study Found In a telehealth visit, for example, clinicians can invest in the relationship by giving "full attention to the patient via the screen, or allowing no visual if that�s what the patient wants." In a more in-depth chronic disease management visit, clinicians can consider the illness context and the patient's life story in order to help the patient identify personal and community resources for managing their condition. As patients are more often treated by health care teams, and with the emergence of telemedicine, virtual visits are becoming more common--often with health care providers who do not know the patient or their health history. The authors conclude, "what we need in a pandemic is not social distancing, but physical distancing with social connectedness."
Implications
- Investing in relationships in all types of visits can personalize the experience for both patients and providers and may also result in more efficient, less costly care.