Index by author

PLAIN LANGUAGE ARTICLE SUMMARIES

SEPTEMBER/OCTOBER 2022, VOL 20, ISS 5

The Issue in Brief

It Will Take a Million Primary Care Team Members

John M. Westfall and Alison N. Huffstetler

Background John M. Westfall, MD, MPH, and Alison Huffstetler, MD, write this edition’s editorial, referencing Bodenheimer’s two-part special report on the history and the present situation of family medicine, with its lack of federal and state funding, dearth of training opportunities, excessive patient panel size, and feeble team support, and his suggestion for how to fix some of these problems moving forward.

What the Editorial Said Westfall and Huffstetler underscore what Bodenheimer argues, that these problems trickle down to a lack of adequate patient care. This in turn affects community health. Westfall and Huffstetler also argue for closing the gap between primary care doctor compensation compared to that of subspecialty doctors.
Furthermore, Westfall and Huffstetler echo Bodenheimer when they argue for the necessity of supporting the development of primary care teams that should include many members, especially those that can provide mental, emotional and behavioral health services – all critical to maintaining public health. In order to implement much-needed changes in primary care, the authors argue for a balance in professionalism (i.e. a sense of calling or duty to commit to a patient, their family and the community) and associationism (i.e. a commitment to one’s own group, discipline or specialty) in the effort to implement the 2020 NASEM report’s recommendations for primary care changes.

Implications/Conclusions

• Westfall and Huffstetler write that professionalism demands a pan-discipline approach that puts people, families, and communities first. They call on everyone in primary care to focus on collaboration and meeting the needs of the community. “Now is the time to live and share our values. Our associations need to prioritize our mutual professional values and place organizational self-interest second to be successful,” the authors write. “Now it is time for the million primary care team members, our patients, and our communities to join. It is primary care's time to lead, together.”

Caregiving in a Pandemic: Health-Related Socioeconomic Vulnerabilities Among Women Caregivers Early in the COVID-19 Pandemic

Jennifer A. Makelarski and colleagues

Background Researchers examined changes in health-related socioeconomic vulnerabilities (social determinants of health that drive people’s overall health and well-being) among family and friends who provided care for a sick or dependent individual during the COVID-19 pandemic.
The team conducted a cross-sectional survey in April 2020, recruiting 3,200 English-speaking U.S. women aged 18 and older, 30% of whom identified as caregivers. Their model measured the adjusted odds of a number of self-reported social factors including financial strain, food/housing insecurity, interpersonal violence and transportation difficulties. Analyses of aggregated survey results were adjusted for caregiving status, age, race/ethnicity, marital status, education, income, number of people in the household, number of children in the household, physical and mental health, and number of comorbidities.

What This Study Found Before the pandemic, 63% of caregivers and 47% of non-caregivers reported one or more social factor challenges, with food insecurity the most prevalent factor (48% and 33% respectively). In the early pandemic, caregivers were more likely than non-caregivers to experience incident and worsening financial strain; incident interpersonal violence; incident food insecurity; incident housing insecurity; and incident transportation difficulties.

Implications

Effective Facilitator Strategies for Supporting Primary Care Practice Change: A Mixed Methods Study

Shannon M. Sweeney and colleagues

Background Researchers conducted a sequential mixed methods study, analyzing data from EvidenceNOW: Advancing Heart Health, a large-scale quality improvement (QI) initiative. Seven regional grantees (i.e. cooperatives) spanning 12 states employed 162 facilitators to work with 1,630 small to medium-size primary care practices to implement best practices for executing meaningful operational change and improving their cardiovascular disease preventive services. Facilitators who had 75% or more of their practices improve on aspirin use, blood pressure control, smoking cessation (ABS) counseling, as well as Change Process Capability Questionnaire (CPCQ) outcomes, were defined as “more effective.” Facilitators who improved less than 50% of practices were considered “less effective.” The team analyzed observational and interview data to identify strategies connected with more effective facilitators.

What This Study Found Practices working with more effective facilitators were associated with a 3.6% higher change in ABS counseling performance (p<.001). More effective facilitators cultivated motivation by adapting processes to local clinics and addressing organizational resistance. More effective facilitators also guided practices to think critically and provided accountability to support change, while also having the ability to describe their work in detail. Less effective facilitators tended to use only one of the strategies and none of them in combination with each other. They also were more rigid in their approach and less able to leverage motivation to customize possible practice changes. Facilitator background, experience, and documentation work did not differentiate the more effective facilitators from less effective facilitators.

Implications

• The use of effective facilitator strategies has implications for enhancing facilitator development and training, and can assist all facilitators in more effectively motivating and supporting practice changes.

Physicians' and Patients' Interruptions in Clinical Practice: A Quantitative Analysis

Ilona Plug and colleagues

Background Researchers conducted a study examining when and how primary care physicians and patients interrupt each other during consultations. The team coded and quantitatively analyzed interruptions (both cooperative and intrusive) in 84 interactions between primary care physicians and patients with common bodily symptoms. They analyzed data using role, gender and consultation phase as predictors of interruption.

What This Study Found Almost 83% of interruptions were cooperative, which preserved the content and flow of interaction (such as when a physician established common ground with a patient by seeking clarification). In the physician group, men were more likely to make an intrusive interruption than women, whereas in the patient group, men were less likely to make an intrusive interruption than women. Patients’ interruptions were more likely to be intrusive than physicians’ in the problem presentation phase, though not in the diagnosis and treatment plan phase.

Implications

Racial and Ethnic Inequities in Use of Preventive Services Among Privately Insured Adults With a Pediatric-Onset Disability

Elham Mahmoudi and colleagues;

Background Patients from historically disenfranchised racial and ethnic groups who also have disabilities face significant burdens accessing primary care services. As a result, they are at higher risk for multimorbidity and adverse health events. Researchers at the University of Michigan examined the use of preventive services among patient populations with cerebral palsy (CP) and spina bifida (SB) to identify racial/ethnic inequities in the use of preventive services among privately insured adults living with congenital disabilities. The team used de-identified private claims data from adult patients with CP/SB over a 10-year period. Analytic models adjusted for age, sex, comorbities, income, education, visit type, completed routine screenings, and inclusion in specific U.S. Census divisions. Their sample was composed of 8,935 White patients, 1,457 Black patients, and 1,243 Hispanic patients.

What This Study Found For most preventive services, privately insured patients with SB/CP, regardless of ethnicity, accessed preventive services at lower rates than the general population. However, researchers found significant racial disparities in care in two areas – annual wellness visits and bone density scans. Among this cohort of privately insured patients living with CP or SB, Black and Hispanic patients were less likely (OR = .50 and OR = .71, respectively) to have had an annual wellness visit than their White counterparts over 10 years. Although bone density screening rates were low across all groups, Black patients were less likely (OR = 0.54) to be screened for bone density than White patients. The researchers did not find inequities in use of other preventive services, including office visits, cholesterol assessment and diabetes screening.

Implications   

• Although inequities in access to care are often attributed to existing gaps in insurance coverage and socioeconomic status, these findings reveal gaps in preventive services among privately insured individuals. The disparity in bone density screening is particularly concerning as patients with CP or SB are at a significantly higher risk for osteoporosis and fractures than the general population. These results suggest that barriers to care may include factors other than insurance coverage. The authors offer several evidence-based solutions to address barriers to care experienced by patients with disabilities, namely increasing the physical accessibility of care centers, increased adoption of telehealth services, and clinician education.

Community Health Workers as Trust Builders and Healers: A Cohort Study in Primary Care

Robert L. Ferrer and colleagues

Background The successful management of type 2 diabetes mellitus (T2DM) requires the active involvement of patients in their own care, which is made more difficult by adverse social conditions including poverty, lack of insurance, or difficult home and neighborhood environments. Clinicians often lack effective systems to help patients navigate these challenges. Researchers evaluated whether the inclusion of a community health worker (CHW) intervention on patient care teams would promote effective long-term T2DM self-management among a Latine, inner city cohort. The researchers measured individual patient progress through three defined stages of T2DM self-management and followed their trajectories of Hb1c and need for emergency or hospital care over a 4-year follow-up. The three periods of care included: 1) Outreach (patient and CHW agree to meet face-to-face); 2) Stabilization (CHW and patient identify and address barriers to self-care); and 3) Self-Care Generativity (Patients’ display internal motivation for self-care, demonstrating skills to manage diabetes in their home context) at the end of a 12-week intervention. The study involved 986 patients.

What This Study Found All three groups demonstrated a significant drop in HbA1c over the study period. Overall, the intervention cohort’s HbA1c levels declined by 2% over the full study period, compared with a 0.055% decrease by a comparison cohort over the same time period. The Self-Care group included 32% of patients and had a faster sustained drop of HbA1c over the 4-year period compared to the other two groups.
In analyses adjusted for age, sex, health insurance status, immigrant status, language preference and prior year utilization, hospitalization rates were two-fold higher in the Stabilization group than in Self-Care. Hospitalizations were 90% higher in Stabilization than in Outreach. Compared with the self-care group, the average count of emergency department visits was 74% higher in the stabilization group p<.001 and 31% higher in the outreach group (p=.03). There were no significant differences in incident rate ratios across groups for urgent care.

Implications

• Researchers concluded that practice-embedded CHWs can sustainably engage people with uncontrolled diabetes who face formidable psychosocial risk factors, helping them create self-management goals and successfully achieve them.

Using State All-Payer Claims Data to Identify the Active Primary Care Workforce: A Novel Study in Virginia

Alison N. Huffstetler and colleagues

Background Researchers present a new approach to identify currently practicing primary care practitioners (PCPs) by using the National Plan and Provider Enumeration System (NPPES) and Virginia All Payers Claims Database (APCD). The authors assert these two databases are more reflective of doctors that are currently practicing primary care as compared to the American Medical Association Masterfile, which may overestimate the primary care workforce.
The team identified all Virginia physicians and their specialty through the NNPES between 2015 and 2019. Active physicians were defined by at least one claim in the APCD. Claims representing wellness visits were used to inclusively identify physicians providing primary care.

What This Study Found In 2019, there were 20,976 active physicians in Virginia, of which 5,899 were classified as primary care physicians. Within primary care, 52.4% had family medicine specialties, with the remaining specialties being internal medicine (18.5%), pediatrics (16.8%), obstetrics and gynecology (11.8%), or other specialists (0.5%). Over five years, the counts and relative percentages of the workforce attributed to primary care remained relatively stable. The authors argue that their method of identifying active physicians with a primary care scope demonstrates a more realistic primary care workforce in Virginia, which is only three-quarters the size of prior estimates.

Implications

• While methods should expand to include advanced practice physicians and to further delineate practice scope, this new approach can be used by policy makers and health care planners to plan for future workforce needs. These transparent methods may be reproduced by other states with an APC to determine primary care size estimates.

Clock-Drawing Test as a Screening Tool for Cognitive Impairment Associated With Fecal Immunochemical Test Collection Errors

Jeanette M. Daly and colleagues

Background The fecal immunochemical test (FIT) is an at-home screening test for colon cancer, routinely recommended for patients over 45 years old. Many patients are more comfortable using the FITs compared to a colonoscopy procedure, but their collection accuracy is dependent on the patient closely following the provided instructions. Researchers included a simple cognitive test, known as the clock-drawing test, to be completed alongside at-home FITs to evaluate the possible contribution of impaired cognition on FIT test completion and errors.

What This Study Found Among 1,448 patients, researchers found an overall FIT collection error rate of 11% (153/1448) – with approximately 25% of these errors from individuals screening positive for cognitive impairment. Also, patients with cognitive impairments were more likely (OR, 1.57) to make errors as compared to those without cognitive impairments. Patients with an eighth grade education level or less were also more likely (OR, 3.76) to make errors in the collection process. The most common collection errors included having too much stool in the vial (34 or 2.3%); stool on the wrong end of the vial (29 or 2.0%); and stool on the wrong side of the slide (13 or 0.9%).

Implications

• The findings indicate the need to consider education level and cognitive function when determining who receives an at-home FIT test. Additionally, using the clock-drawing test to screen patient ability to follow directions for sample collection may help clinicians better identify patients for whom at-home screening may not be a best-fit screening solution.

Family Physicians Stopping Practice During the COVID-19 Pandemic in Ontario, Canada

Tara Kiran and colleagues

Background Family doctors faced significant challenges in the early months of the COVID-19 pandemic in Canada, including reduced revenue, decreased retention of office staff, difficulty obtaining equipment, and decreased morale. Canadian researchers conducted two analyses using billing claims administrative data to understand the number and characteristics of physicians who stopped work in the first six months of the pandemic in Ontario, Canada and to learn whether more family physicians in Ontario stopped working during the COVID-19 pandemic compared to previous years.

What This Study Found Researchers found that 3.1% of physicians working in 2019 (385 out of 12,247 doctors) reported no billings in the first six months of the pandemic. Compared with other family physicians, a higher portion were aged 75 or older; had fee-for-service reimbursement; had a patient panel size of under 500; and worked less than other physicians in the previous year. The rate at which family physicians stopped working rose from an average of 1.6% for the years between 2010 and 2019 compared to 3% who stopped work in 2020.

Implications

• Although the absolute number of physicians stopping work was small, the impact on patients and communities is substantial considering that the profession is experiencing a primary care physician shortage. If this trend is true for other communities, the COVID pandemic may have exacerbated the primary care physician shortage.

Revitalizing Primary Care, Part 1: Root Causes of Primary Care's Problems

Revitalizing Primary Care, Part 2: Hopes for the Future

Thomas Bodenheimer

Background Thomas Bodenheimer, MD, MPH, professor emeritus of the Department of Family and Community Medicine at the University of California San Francisco, writes a two-part special report highlighting challenges faced by primary care in the United States – and offering solutions to some of those problems.

What This Report Said Bodenheimer argues that low rates of national health expenditures dedicated to primary care, coupled with excessive patient panel sizes (or

the number of individual patients under the care of a specific clinician), has led to an increase in physician burnout and decreased access to care for patients. He notes that the United States has spent significantly less on primary care than other Organisation for Economic Co-operation and Development (OECD) countries, with 5.4% of total health expenditures in the U.S. directed towards primary care, compared to 7.8% in 22 other OECD countries. In the context of limited funding, he observes that primary care clinicians are caring for larger numbers of patients – with the average size of patient panels currently estimated at more than 2,100 patients per clinician. Bodenheimer also cites increasing electronic health record (EHR) documentation requirements and declining numbers of new primary care doctors as additional contributing factors to the profession's current challenges.

Implications

• Bodenheimer proposes three approaches to improve primary care, including increasing primary care spending: state-level legislation to increase primary health care funding; and the elimination of Medicare’s disparity between primary care and specialty reimbursements. He also proposes more emphasis on multidisciplinary teams to support primary care in managing large panels of patients. “With adequate primary care spending and powerful teams, primary care can become accessible to patients and joyful to all,” Bodenheimer concludes.

The Joy and Grief of Knowing Your Patient

Saba Fatima
Background Saba Fatima, an early-career pediatrician, examines how in maintaining boundaries between herself and her young patients and their caregivers, her work eventually led her to feel that the care she provided had no meaning for her and that she had become like a “robot.” This was far from the goals she had set as a doctor-in-training, when her mission and passion were to form meaningful bonds with her patients.

What This Essay Said Taking to heart the boundary lessons she learned in medical school, she attempted to treat patients in a way where she knew little about their stories – only their illnesses and diseases – and, in turn, created an environment where her patients knew little about her. Approaching the end of her residency, she began reflecting on the meaningful moments she had collected along the way. To her disbelief, her mind felt “blank and hollow.”
Fatima began listening to her patients and their caregivers, learning about their lives and personal narratives. In doing so, she began to find meaning again in her work. Fatima realized, however, that being a more empathetic doctor has its costs – namely heartbreak and self-questioning about whether she should have gotten so close with her patients. “Is there a perfect balance to the humanistic side of medicine?” she writes. “What is the secret sauce to (loving) your patient, but just not enough to break your heart. For now, I continue to listen as I wonder: is the joy worth the grief?

The Face of God Revealed

Timothy P. Daaleman

Background Timothy Daaleman, DO, MPH., a professor of family medicine, writes an essay about his journey with a patient grappling with a terminal cancer, and the steadfastness of the patient’s estranged wife who provided care as death approached.

What This Essay Said As a physician practicing in the shadow of the COVID-19 pandemic, Daaleman called into question the nature of his relationships with those he cared for, and how he thought about God or the “Greater Reality.” With a worldview that was no longer optimistic and hopeful, Daaleman’s core beliefs about being a physician were hollowed out, particularly the relevance of his doctoring in the lives of his patients.
The face of God was revealed to Daaleman by witnessing a wife's incomprehensible commitment to her husband at the end of his life. This epiphany stirred something in Daaleman and he writes, “If the walls of my fears and doubts can move enough for these waters to flow, I may care for others with fathomless mercy, with love that is sometimes incomprehensible, and with steadfastness that is wearied but never broken.”

Do I Return to the Community That Traumatized Me?

Minna Wybrecht

Background Minna Wybrecht, a fourth-year medical student at the University of Michigan, writes about her decision to return to the neighborhood where she grew up, a community grappling with poverty, substance abuse, and gun violence. It was in leaving her community to attend the university that she was able to find personal safety and have the opportunity for personal reflection.

What This Essay Said Wybrecht describes going back to her hometown to do a monthlong clinical elective. The experience facilitated “candid and vulnerable introspection” and prompted her to ask herself how she could reconcile the paradox that her hometown was both traumatizing and wonderful. She also asked herself what she owed her community and how she could serve out of compassion and not guilt. Through the elective, she learned how to honor the fact that her hometown is a place of ‘tenacious, struggling, beautiful people’ and to resolve her survivor’s guilt while avoiding a savior complex mindset.
“To serve others, I owe it to myself to be safe and heal my own wounds first,” Wybrecht writes. “Ultimately, I decided I want to partake in the story of humanity’s inexorable will to survive in the face of structural barriers.”

Facing the Digital Divide: Increasing Video Visits Among Veterans Experiencing Homelessness

Alyson Prince and colleagues

Background Facing the Digital Divide: Increasing Video Visits Among Veterans Experiencing Homelessness - An interdisciplinary team of primary care clinicians implemented a quality improvement project to increase video visits for military veterans experiencing homelessness (VEH). The project addressed patient and clinician technology barriers to bridge access to care for VEH. They also highlighted an interprofessional team approach that strengthened telemedicine practice during the COVID-19 pandemic and beyond. The proportion of video visits among telehealth visits doubled in 16 weeks from 4.8% to 10.3% and continued to increase during the following month (4.8% vs 12.9%, P <0.001). The team found that standardized video visit workflows, sustained education, and maximizing resources available at the VA proved essential to increasing video visit use.

A One Health Clinic for People Experiencing Homelessness and Their Animals: Treating the Human-Animal Unit

Background A One Health Clinic for People Experiencing Homelessness and Their Animals: Treating the Human-Animal Unit - Researchers created the Seattle One Health Clinic (OHC) in 2018 to provide primary health care and veterinary care concurrently in a population of individuals experiencing homelessness and their companion animals. A multidisciplinary team cares for youth without homes and their pets in a clinical space at New Horizons, an enhanced youth shelter in Seattle. The OHC is currently offered as a four-hour session twice monthly. From 2018-2021, 236 animals were seen. In 2019, 65 animals were seen by veterinarians, while clinic staff saw 45 human patients. Twenty-one of these human patients ultimately returned to the clinic for additional care. People often brought more than one animal for care at the OHC, and occasionally, human patients would leave before being evaluated by a human health practitioner. The OHC created a free toolkit of protocols and best practices for starting a One Health Clinic for other groups in the U.S. and Canada. Find it at www.onehealthclinic.org