Table of Contents
In Brief
The Issue in Brief, November-December 2021
Trust and Relationships Remain at the Heart of Primary Care
Kenneth W. Lin
Background Family physician and blogger Kenneth W. Lin, MD, MPH, writes about the theme of trust and relationships in primary care.
What This Study Found Linzer et al’s research, published in this edition of Annals, identified four features
of organizational culture that correlate with high clinician trust in the organization
and high patient trust in the clinicians: quality; communication and information;
clinician cohesion; and clinician-leader value alignment. Organizations that build
trust among physicians may have happier clinicians and more satisfied patients, according
to Lin. Lin also responds to Beach et al’s findings that clinicians were less likely
to give patients opportunities to elaborate on emotions as clinic time elapsed. Other
papers in this edition of Annals discuss the tension of competing priorities between
independent physicians and clinicians who work in larger health care organizations.
Implications
- Lin suggests that patients and doctors alike will benefit from promoting doctor-patient relationships and trust, while also providing physicians and other health professionals with the support of a larger medical system.
Annual Wellness Visits for Persons With Physical Disabilities Before and After ACA Implementation
Diane M. Harper and colleagues
Background Researchers documented the use of Annual Wellness Visits (AWV) by persons with physical disabilities during the Affordable Care Act rollout. They extracted data from an administrative claims database including both Medicare Advantage and commercial insurance payers from 2008-2016, and looked specifically at unique yearly wellness visits for adults with physical disabilities. They used interrupted time series analysis to compare AWV use by insurance type, gender, disability type and race over time.
What This Study Found Results showed that by 2016, AWV reached 47.6% (44.7, 50.8) among commercial insurance–covered white women with congenital disabilities (spina bifida and cerebral palsy). In contrast, the rate among commercially insured Hispanic men with acquired disabilities (spinal cord injuries, hemi-, para- and quadriplegia) was lower at 21.6% (18.4, 25.2). Medicare Advantage-insured Black and Hispanic men with acquired disabilities had a similarly low level of AWV use. The ACA mandated zero copays, allowing persons with physical disabilities the option for screening without cost. Insurance and gender significantly influenced AWV use, followed by disability type and race. Overall, the highest AWV use for persons with disabilities is nearly 15% less than the 62% AWV use threshold seen in the general population.
Implications
Craig J. Bryan and colleagues
Background Researchers from academia and the U.S. military sought to determine if suicide risk screening can be meaningfully improved to better identify highest-risk patients. Patients eligible to receive medical treatment from the U.S. Department of Defense medical system were recruited from six military primary care clinics in five military installations across the country.
What This Study Found Adding one of three Suicide Cognitions Scale (SCS) items to the Patient Questionaarie (PHQ-9) self report measure during routine primary care clinical visits improved the accuracy of identifying those patients who were at the highest risk of suicidal behavior within a month of screening positive.
Implications
Improving Quality Improvement Capacity and Clinical Performance in Small Primary Care Practices
Katie F. Coleman and colleagues
Background A team of family medicine researchers conducted an assessment to determine if the
implementation of policies and workflows designed to improve quality of care in smaller
primary care practices was associated with improved health outcomes for patients with
cardiovascular disease. The study also examined whether enhancements in quality improvement
capacity are associated with a change in clinic performance.
During the15-month intervention, study participants received training on how to extract
clinical quality measures from patient data and implement QI innovations using plan-do-study-act
cycles of improvement. Performance on three cardiovascular quality measures —appropriate
aspirin use, blood pressure (BP) control, and tobacco screening/cessation counseling—were
reported by clinics at baseline and follow-up.
What This Study Found Within 15 months of the intervention, practices were able to make improvements in all areas, with most improvements occurring in the domains related to QI where facilitators focused their efforts. Additionally, the researchers observed that for each one-point increase in the QICA score, practices were 24% more likely to reach the Million Hearts campaign goal of 70% of patients with well-controlled blood pressure.
Implications
Taressa K. Fraze and colleagues
Background Health professionals recognize that social factors such as food, housing and economic insecurity, affect health outcomes. Researchers conducted a qualitative study to gain practical insights into strategies used by clinicians, leaders and policymakers to address patients’ social needs in the United States. They selected sites to ensure diversity in ownership, structure, geography and urbanicity, ranging from small primary care practices to multi-state health systems. Interviews focused on how organizations develop and implement case management-style programs to assist patients with social needs including staffing, assistance intensity and use of referrals to community-based organizations.
What This Study Found The authors identified four barriers to addressing patients’ social needs including: 1) effectively engaging CBOs; 2) obtaining buy-in from clinical staff; 3) considering patients’ perspectives; and 4) ensuring program sustainability.
Implications
Clinician Response to Patient Emotion: Impact on Subsequent Communication and Visit Length
Mary Catherine Beach and colleagues
Background Beach et al evaluated the association of clinician responses to patient emotions during a clinic visit. Researchers audio-recorded 41 clinicians with 342 unique patients as part of the maRIPOHSA (Maximizing Respect and Improving Patient Outcomes in HIV and Substance Abuse) Study. They classified physicians’ responses to patient emotions as either providing space or reducing space for patients to elaborate on their emotions. Within these categories, they identified these responses as either explicit or non-explicit, meaning that the physician either named the emotion in their response or did not.
What This Study Found They found that patients repeated their emotions when physicians provided space. When
physicians explicitly addressed emotions, visit length was shorter. Finally, they
noticed that as the clinic visit progressed, the physician was less likely to respond
by providing space.
The study took place in an HIV ambulatory care center, where patients received both
specialty HIV care and primary care. The mean visit length was 30.4 minutes with 1,028
emotional expressions total. Most clinician responses provided space (81%) and most
were non-explicit (56%).
Implications
Mark Linzer and colleagues
Background Researchers sought to determine the characteristics of health organizations that promoted clinician trust. They further hypothesized that clinician trust may be correlated with patients’ trust in their clinician.
What This Study Found Trust in the medical profession has dropped from a high of 75% in a 1966 survey to a low of 33% in 2018. “High clinician-high patient” trust occurred when clinicians perceived their organizational culture as having: 1) an emphasis on quality; 2) an emphasis on communication and information; 3) cohesiveness among clinicians; and 4) values aligned between clinicians and their leaders.
Implications
Ava Skolnik and colleagues
Background Authors of this special report note that, although ending the COVID-19 pandemic is of utmost importance, it is critical to recover from what they describe as a “severe” disruption to routine vaccination services, which has resulted in “considerable deficits'' of vaccination rates across all age groups.
What This Study Found Vaccinations that have seen drops include measles-mumps-rubella (MMR), diphtheria, tetanus and acellular pertussis (DTaP) and polio, as well as HPV vaccination rates for children 9-12. This drop in routine vaccinations may have dire consequences to future population health and a potential to strain an already overtaxed health system.
Implications
Cassie D. Turner and colleagues
Background Turner et al's study assessed the characteristics of low-income, Black veteran men who participated in a peer coaching program called Technologically Enhanced Coaching: A Program to Improve Diabetes Outcomes (VA-TEC) at the John D. Dingell VA Medical Center in Detroit and analyzed their levels of program engagement and health outcomes at six and 12 months.
What This Study Found The authors found that autonomy-supportive peer coaching is associated with higher levels of patient engagement. At six-month follow-up, participants who evaluated their peer coaches as highly autonomy-supportive were more likely to have engaged in the program than participants who rated their coaches lower on autonomy supportiveness. Additionally, the authors highlight characteristics of peer coaches who contributed to increased patient engagement including: shared background and lived experiences with participants; sharing information on resources and self-management strategies that were helpful in their own lives; being encouraging, supportive, and authentic during sessions; and being reliable and consistent.
Implications
Catherine Hudon and colleagues
Background Engaging stakeholders in case study development may enhance implementation of complex health care interventions in primary care.
What This Study Found Researchers defined several levels of stakeholder engagement of varying intensity,
from full involvement in all stages of the research to involvement in certain stages.
They then provide twelve steps for conducting case studies with a participatory approach,
illustrated by a practical example of how one primary care research team used the
case study approach to assess the implementation of a complex health care innovation.
Researchers defined several levels of stakeholder engagement of varying intensity,
from full involvement in all stages of the research to involvement in certain stages.
They then provide twelve steps for conducting case studies with a participatory approach,
illustrated by a practical example of how one primary care research team used the
case study approach to assess the implementation of a complex health care innovation.
Implications
Measuring Primary Care Across 35 OECD Countries
Rebecca S. Etz and colleagues
Background Researchers administered the Person-Centered Primary Care Measure in 28 languages to 35 Organisation for Economic Cooperation and Development countries to examine the reliability and validity of the measure and to explore the differences in primary care across 35 OECD countries. The PCPCM is an 11-item, patient-reported measure developed in 2017 to assess primary care qualities such as health care accessibility, advocacy, community context, family context, goal-oriented care, health promotion, integration and relationship. Survey constructs are based on what patients, clinicians and, to a lesser extent, payers say is most important to them in primary care.
What This Study Found The PCPCM showed solid psychometric properties across all languages and countries, according to the study.
Implications
The Lost Pillar: Does Continuity of Care Still Matter?
David Loxterkamp
Background David Loxterkamp, MD looks back at his career as a practicing physician in rural Maine. He reflects on how family medicine’s emphasis on continuity of care has shaped his sense of identity and purpose, and is dismayed by the erosion of this value in primary care.
What This Study Found Despite research that establishes the benefits of relational continuity in the lives of patients and their physicians, the author sees a marked shift in family medicine practices toward the “transactional,” episodic care of mainstream medicine.
Implications
Parenting My Transgender Child: From Loss to Acceptance
Justine Larson
Background Child and adolescent psychologist, Justine Larson, MD, writes about her child Neo, who, at age 11, informed her that he was a boy and not a girl, as assigned at birth.
What This Study Found Despite Dr. Larson’s training, she struggled to accept her child’s decision and had to learn how to best support Neo. She writes about how she and her husband had to navigate the adjustments to Neo’s new pronoun, name change, transition at school, and informing friends and family about the changes.
Implications
John C. Matulis III and colleagues
Background Authors John C. Matulis and Suzette Barakat, two early career internal medicine physicians at the Mayo Clinic in Rochester, Minn., created a forum for themselves and their health care colleagues to review challenging cases and seek input on difficult clinician decision-making scenarios, but also to provide an informal setting for networking.
What This Study Found The conference improved a sense of belonging among participants by 25 points and enthusiasm by 18 points on a 100-point scale, although there were non-significant improvements in overall quality of life scores, burnout scores and meaning in work scores.
Implications
- The authors believe a conference similar to the Mayo Clinic’s ‘Cases and Conundrums’ may be an effective intervention for building community among early career clinicians while improving patient care.
Meredith C. Buck and colleagues
Background Members of the Mayo Clinic Family Medicine Residency-Eau Claire created a medication-assisted treatment program for opioid disorders within its practice. They did this by taking over care for a large group of established patients from a single family physician who was leaving the community. Part of this entailed the development of didactic sessions and documentation templates, which facilitated treatment and seamless patient scheduling with residency providers.
What This Study Found The new program helped patients and their original physician to avoid the challenges of identifying other providers and possibly being unable to access care.
Implications
Community Paramedic Mobile COVID-19 Unit Serving People Experiencing Homelessness
Zachary R. Stickler and colleagues
Background Members of the Mayo Clinic Ambulance Service partnered with the Olmsted County Housing Stability Team to provide timely, person-centered care to COVID-19 positive individuals experiencing homelessness.
What This Study Found The unit, which cared for 13 people in its first two weeks, is currently working toward
expansion to all shelters and encampments, not limited to individuals with confirmed
COVID-19 infection.
Jonathan L. Robbins and colleagues
Background The internal medicine clinic at Oregon Health & Science University formed an opioid review board to set clinic policy for safe opioid prescribing aligned with state and federal guidelines and evidence-based practices.
What This Study Found The ORB has updated the patient-physician opioid agreement and now conducts formal case reviews of two to four patients each month. The ORB focuses on the process of case reviews and has improved clinical alignment with state and federal guidelines.
Implications