Table of Contents
The Issue in Brief
Winston R. Liaw , and colleagues
Background As the US population ages, grows, and has more health insurance, there are concerns about whether there is a large enough health care workforce to meet demand. This study examines the projected primary care physician shortage through 2035.
What This Study Found More than 44,000 additional primary care physicians will be needed by 2035 to meet the demands of the US population, assuming current ratios of primary care physicians to population and current physician retirement rates. To eliminate projected shortages, a 21 percent increase in primary care residency production will be needed. From 2015 to 2035, at current production rates, there will be 169,029 new primary care physicians in the US. Because of retiring primary care physicians, however, this production cannot match need, resulting in a shortage of 33,283 primary care physicians by 2035.
Implications
- This deficit could be eliminated by adding nearly 2,200 first-year residency positions by 2020, a 27 percent increase.
- If clinicians begin seeing fewer patients, in keeping with new health care delivery models, the projected shortage would substantially increase.
Timeliness of Outpatient Follow-up: An Evidence-Based Approach for Planning After Hospital Discharge
C. Annette DuBard , and colleagues
Background Timely outpatient follow-up is considered key to reducing hospital readmissions. This study looks at the optimal timing of hospital follow-up for patients of varying complexity.
What This Study Found Although most patients do not meaningfully benefit from early outpatient follow-up, high risk patients do. Among patients with up to one chronic or acute condition, readmissions are uncommon, and the timing of outpatient follow-up for up to 30 days has little effect. Among patients with multiple chronic conditions, however, follow-up within 7 days is associated with meaningful reductions in risk of readmission.
Implications
- While healthier patients and those with greater social support or self-management skills may be better equipped to make and attend an earlier follow-up appointment, it can potentially delay care for those with more complex needs.
- The authors suggest that transitional care resources can best be used to ensure that highest risk patients receive follow-up within 7 days.
Elizabeth A. Bayliss , and colleagues
Background Continuity of care refers to an ongoing health care relationship. Low continuity of care is associated with more inappropriate medication prescribing, higher cost of care, more avoidable hospitalizations, and greater use of emergency services. This study looks at whether interpersonal continuity (seeing the same clinician over time) is associated with rates of hospital admissions and emergency department use among seniors with multiple chronic medical conditions. The study takes place in an integrated system of health care delivery with high informational continuity (clinical information is available to all clinicians caring for a patient) through shared electronic records.
What This Study Found Greater primary care and specialty care continuity are each associated with lower inpatient admission and lower risk of emergency department visits. For patients with three or more primary care and three or more specialty care visits, specialty care continuity, but not primary care continuity, is associated with a decreased risk of hospital admissions; primary care continuity, but not specialty care continuity, is associated with a decreased risk of emergency department visits.
Implications
- Different subgroups of patients will benefit from continuity with primary and specialty care clinicians depending on their care needs.
- Interpersonal continuity may have a beneficial effect on utilization independent of the informational continuity provided by electronic medical records.
Rachel Willard-Grace , and colleagues
Background Health coaching can give people with chronic illnesses the knowledge, skills, and confidence to manage their conditions. This study tests the effectiveness of health coaching by medical assistants to improve indicators of health among low-income patients with uncontrolled diabetes, high blood pressure, and high cholesterol levels.
What This Study Found Health coaching by medical assistants is a promising way to improve indicators of health for people with common chronic conditions. In this study, almost twice as many patients who received health coaching achieved their diabetes goals. At the larger study site, health coached patients were more likely to achieve their cholesterol goals. There was no significant difference in the proportion of patients meeting their blood pressure goals.
Implications
- Medical assistants can successfully serve as health coaches to improve health indicators for some common chronic conditions.
- The medical assistant health coaching model may help solve barriers of time, resources and cultural concordance faced by many primary care practices seeking to implement self-management support.
Marlon P. Mundt , and colleagues
Background Cardiovascular disease (CVD) is the leading cause of death and disease in the US. Primary care teams, which provide support and share responsibilities for patient care, offer a unique opportunity to improve quality and lower medical costs for patients with CVD. This study evaluates the association between primary care team communication, interaction, and coordination (i.e., social networks), quality of care, and costs for patients with CVD.
What This Study Found Primary care teams that are more interconnected, less centralized, and have a shared team vision are better positioned to deliver high-quality cardiovascular disease care at a lower cost. Teams with more members reporting daily interactions with a greater number of team members show better quality of care, with a 38 percent reduction in hospital days and, on average, $516 less spent per patient in the previous 12 months. The study findings suggest that teams with more daily face-to-face interactions have fewer urgent care and emergency department visits and $594 less spent in medical costs per patient in the previous 12 months.
Implications
- In this study, a team's shared vision of goals and expectations mediates the relationship between social network structures and patient quality of care outcomes.
Simon J. Griffin , and colleagues
Background Many organizations recommend population screening for diabetes. This study assesses the long-term effects of such screening.
What This Study Found At the population level, screening high risk individuals for diabetes appears to have limited impact on cardiovascular disease, self-rated health status and health behavior. In a study of 18,875 individuals aged 40 to 69 years at high risk of diabetes, 2.9 percent of those eligible for screening were diagnosed with diabetes. After seven years, there were no significant differences between the screening and control groups in terms of reported heart attack or stroke, self-rated health status, physical activity, smoking status or alcohol consumption. Diabetes screening did not have a negative effect on self-rated functional status or health utility and did not lead to unhealthy behaviors due to false reassurance or to an increase in health service use.
Implications
- The authors see no long-term beneficial effect of screening for type 2 diabetes at the population level. They conclude that a single round of screening may be associated with benefits among the minority whose previously undiagnosed diabetes is detected, but it appears unlikely to affect the health of the population as a whole.
Predictors of Chronic Abdominal Pain Affecting the Well-Being of Children in Primary Care
Leo A. A. Spee , and colleagues
Background Abdominal pain is a frequent complaint among children but its prognosis is difficult to predict. The ability to identify children at risk for long-term abdominal pain would help clinicians make more appropriate management decisions at an earlier stage. This study seeks to identify characteristics that can predict chronic abdominal pain severe enough to influence the child?s wellbeing at 1-year follow-up.
What This Study Found More than one in three children coming to a family practice with abdominal pain have persistent pain affecting quality of life after one year. Increased age, waking up at night with pain, high levels of other physical complaints, and chronic abdominal pain at the initial visit independently predict chronic pain at one year. The probability of having chronic abdominal pain after one year ranges from 19 percent in children with none of the predictors to 66 percent among those having three or four. However, the predictors collectively explain only 14 percent of variance in the development of chronic abdominal pain.
Implications
- On the basis of medical evaluation alone, the family physician is unable to accurately predict the prognosis of a child with abdominal pain. Other yet to be identified psychosocial, environmental or family stressors may play a role.
Relationships of Multimorbidity and Income With Hospital Admissions in 3 Health Care Systems
Stewart W. Mercer , and colleagues
Background This study looks at the relationships between income, hospital admissions, and multimorbidity (having two or more chronic conditions) in three countries with differing health care systems: Scotland, where a public healthcare system provides universal coverage; China, which does not provide universal health coverage and patients usually pay out-of-pocket; and Hong Kong, which has a dual-track system of both public and private health care.
What This Study Found Higher levels of multimorbidity are related to higher hospital admissions in all three settings. In Scotland, poorer patients have more hospital admissions, while China shows the opposite: those with lower incomes have lower odds of hospitalization. In Hong Kong, poorer people are more likely to be admitted to public hospitals, but less likely to be admitted to private ones.
Implications
- These findings offer insights into how health care systems might be made more equitable and effective.
- Strategies to improve equitable health care should consider the impact of socioeconomic status on the use of health care resources, particularly among populations with high rates of multimorbidity.
Recommendations for a Mixed Methods Approach to Evaluating the Patient-Centered Medical Home
Roberta E. Goldman , and colleagues
Background The Patient-Centered Medical Home (PCMH) is intended to transform primary care practices by combining the best primary care attributes with new ways of structuring and coordinating care, engaging patients, improving health outcomes, providing a better patient experience, improving efficiency and use of health information technology, and reducing costs. This study develops a methodology for identifying how and why transformation occurs in primary care practices.
What This Study Found PCMH evaluation must be comprehensive enough to assess and explain the context of transformation in different primary care practices and the experiences of diverse stakeholders. The methods and measures proposed in this study are intended to be used together and include survey instruments, PCMH meta-measures, patient outcomes, quality measures, qualitative interviews, participant observation, and process evaluation.
Implications
- This approach, the authors conclude, can foster insights about how transformation affects critical outcomes to achieve meaningful, patient-centered, high-quality, and cost-effective sustainable change among diverse primary care practices. These insights, in turn, can inform recommendations for practice facilitation that can most effectively achieve the goals of the PCMH model.
Why Medical Schools Are Tolerant of Unethical Behavior
Edison I. de Oliveira Vidal , and colleagues
Background Unethical and unprofessional behavior in medical schools and health organizations have been associated with medical errors, increased costs, and preventable harm to patients, students, residents, nurses and other physicians. In this essay, physicians in Sao Paulo, Brazil ask, "Why is unethical behavior tolerated in medical schools?"
What This Study Found Reasons why medical schools are tolerant of unethical faculty behavior can include barriers to reporting, the reluctance of deans and directors to look for unethical behavior in colleagues, the fact that people have become accustomed to a disrespectful health care environment, and the fact that accreditation of medical schools does not usually cover the processes or outcomes associated with fostering ethical behavior. Promising efforts are underway at several health care institutions aimed at preventing, reducing and mitigating unethical/unprofessional behaviors in medical schools.
Implications
- The authors call for changes to the organization and underlying culture of health care institutions.
Lauren S. Hughes
Background n/a
A family physician reflects on her struggle to reconcile the experience of witnessing a man commit suicide during her residency and how it shaped her personally and professionally. She describes the powerlessness she felt in the face of inevitability, the questions of professional boundaries that resulted, and how the experience challenged her sense of capability to fulfill the very calling that brought her into medicine--to help patients fix important problems in their lives.