Docs with their eyes on the clock? The effect of time pressures on primary care productivity

Physicians' responses to time pressure: Experimental evidence on treatment quality and documentation behaviour

BACKGROUND

In hospitals, decisions are often made under time pressure. There is, however, little evidence on how time pressure affects the quality of treatment and the documentation behaviour of physicians.

SETTING

We implemented a controlled laboratory experiment with a healthcare framing in which international medical students in the Czech Republic treated patients in the role of hospital physicians. We varied the presence of time pressure and a documentation task.

RESULTS

We observed worse treatment quality when individuals were faced with a combination of a documentation task and time pressure. In line with the concept of the speed-accuracy trade-off, we showed that quality changes are likely driven by less accuracy. Finally, we showed that while documentation quality was relatively high overall, time pressure significantly lowered the latter leading to a higher hypothetical profit loss for the hospital.

CONCLUSIONS

Our results suggest that policy reforms aimed at increasing staffing and promoting novel technologies that facilitate physicians' treatment decisions and support their documentation work in the hospital sector might be promising means of improving the treatment quality and reducing inefficiencies potentially caused by documentation errors.

Barriers to Providing Optimal Care in Idaho from the Perspective of Healthcare Providers: A Descriptive Analysis

Background/Objectives: Few studies have assessed barriers to providing care from the perspective of interprofessional healthcare providers. Despite Idaho's predominantly rural geography, limited research exists assessing barriers to providing care within the state. This study sought to assess barriers to providing optimal healthcare using a sample of 400 healthcare providers at 22 clinic sites across the state. Methods: A barriers to providing optimal care 9-factor, 41-item survey was modified from an existing survey. Healthcare providers rated barrier items using an 11-point Likert scale. The survey was distributed to a convenience sample of healthcare providers in 22 different clinic sites in rural Idaho. Results: Four hundred interprofessional healthcare providers in Idaho across 13 professional disciplines completed surveys. Items in the Service Access (mean = 7.14), Patient Complexity (mean = 6.59), and Resource Limitations (mean = 6.18) factors were reported as the most commonly perceived barriers to providing optimal care. Conclusions: Few studies have assessed rural interprofessional providers' perceived barriers to providing optimal, high-quality, care, specifically in the rural state of Idaho, where healthcare services are often not equitable compared to urban regions. The results suggest that commonly perceived barriers exist throughout the state, particularly Service Access, Patient Complexity, and Resource Limitations. Further research is needed to develop data-driven decisions to address these concerns.

The effect of workload on primary care doctors on referral rates and prescription patterns: evidence from English NHS

This paper investigates the impact of workload pressure on primary care outcomes using a unique dataset from English general practices. Leveraging the absence of General Practitioner (GP) colleagues as an instrumental variable, we find that increased workload leads to an increase in prescription rates of antibiotics as well as in the share of assessment referrals. On the other hand, the quantity and frequency of psychotropics decreases. When there is an absence, workload is intensified mostly on GP partners, and the mode of consultation shifts toward remote interactions as a response to higher workload pressure. The effects are more pronounced for patients above 65 years-old and those in Short-staffed practices. Our study sheds light on the intricate relationship between workload pressure and patient care decisions in primary care settings.

Inbox message prioritization and management approaches in primary care

Objectives

Patient messaging to clinicians has dramatically increased since the pandemic, leading to informatics efforts to categorize incoming messages. We examined how message prioritization (as distinct from categorization) occurs in primary care, and how primary care clinicians managed their inbox workflows.

Materials and Methods

Semi-structured interviews and inbox work observations with 11 primary care clinicians at MedStar Health. We analyzed interview and observation transcripts and identified themes and subthemes related to prioritization and inbox workflows.

Results

Clinicians widely reported that they did not prioritize messages due to time constraints and the necessity of attending to all messages, which made any prioritization purely additive to overall inbox time. We identified 6 themes and 14 subthemes related to managing inbox workloads. The top themes were (1) establishing workflow norms with different teams, primarily medical assistants (MAs); (2) boundary-setting with patients, other clinicians, and with themselves; and (3) message classification heuristics that allowed clinicians to mentally categorize messages that required follow-up, messages that could be quickly deleted or acknowledged, and purely informational messages that ranged in clinical utility from tedious to valuable for care coordination.

Discussion

Time constraints in primary care prevent clinicians from prioritizing their inbox messages for increased efficiency. Involvement of MAs and co-located staff was successful; however, standardization was needed for messaging workflows that involved centralized resources like call centers. Organizations should consider ways in which they can support the establishment and maintenance of boundaries, to avoid this responsibility falling entirely on clinicians.

Conclusion

Clinicians generally lack the time to prioritize patient messages. Future research should explore the efficacy of collaborative inbox workflows for time-savings and management of patient messages.

Specific Medication Literacy in Older Adults with Asthma

Purpose

To explore specific medication literacy (SML) of older adults and associations of SML strength.

Methods

This was an observational study. Participants were at least 60 years old, with an asthma diagnosis and in good health. Data were collected by a registered nurse researcher. The SML data collection instrument gathered information about each medication a participant used: name, purpose, how taken, special instructions, adverse effects, and drug-drug or drug-disease interactions. An SML scoring rubric was developed.

Results

All could provide name, and most provided purpose, how taken. The lowest SML domains were side effects and interactions. Age at time of asthma diagnosis correlated with stronger SML scores and living in a disadvantaged neighborhood correlated with lower SML scores.

Discussion

Gaps in medication literacy may create less ability to self-monitor. Patients want medication literacy but struggle with appropriate, individualized, information.

Conclusion

The study provides insights on gaps and opportunities for SML.

Time is money: general practitioners' reflections on the fee-for-service system

BACKGROUND

Fee-for-service is a common payment model for remunerating general practitioners (GPs) in OECD countries. In Norway, GPs earn two-thirds of their income through fee-for-service, which is determined by the number of consultations and procedures they register as fees. In general, fee-for-service incentivises many and short consultations and is associated with high service provision. GPs act as gatekeepers for various treatments and interventions, such as addictive drugs, antibiotics, referrals, and sickness certification. This study aims to explore GPs' reflections on and perceptions of the fee-for-service system, with a specific focus on its potential impact on gatekeeping decisions.

METHODS

We conducted six focus group interviews with 33 GPs in 2022 in Norway. We analysed the data using thematic analysis.

RESULTS

We identified three main themes related to GPs' reflections and perceptions of the fee-for-service system. First, the participants were aware of the profitability of different fees and described potential strategies to increase their income, such as having shorter consultations or performing routine procedures on all patients. Second, the participants acknowledged that the fees might influence GP behaviour. Two perspectives on the fees were present in the discussions: fees as incentives and fees as compensation. The participants reported that financial incentives were not directly decisive in gatekeeping decisions, but that rejecting requests required substantially more time compared to granting them. Consequently, time constraints may contribute to GPs' decisions to grant patient requests even when the requests are deemed unreasonable. Last, the participants reported challenges with remembering and interpreting fees, especially complex fees.

CONCLUSIONS

GPs are aware of the profitability within the fee-for-service system, believe that fee-for-service may influence their decision-making, and face challenges with remembering and interpreting certain fees. Furthermore, the fee-for-service system can potentially affect GPs' gatekeeping decisions by incentivising shorter consultations, which may result in increased consultations with inadequate time to reject unnecessary treatments.

Ethical acceptability of telemedicine: Nursing home resident's perspective on telemedical consultations

Objective

The use of telemedicine in health care has recently expanded, and with it the need to evaluate its use from an ethical perspective. Studies investigating the ethical acceptability of telemedical consultations (TC) in nursing homes are lacking, and in particular, the perspectives and experiences of older adults with TC are underrepresented. The objective of this study is to identify ethically relevant parameters in the acute care of nursing home residents using TC and to derive recommendations.

Methods

A combination of qualitative research methods was employed to gain a comprehensive understanding of the research topic. These included semi-structured face-to-face interviews and participant observations. Due to the phased design of the cluster-randomized controlled intervention trial in the overarching study project, our investigations were carried out in phases before and after the implementation of the telemedical systems in the nursing homes.

Results

We identified various ethical challenges associated with the use of TC, including those related to autonomy, participation, privacy, self-conception, beneficence, security and justice. Our analysis indicates that the use of TC for nursing home residents is ethically acceptable, provided that several recommendations to promote acceptability are considered.

Conclusion

Our findings provide insights into the variety of ethical challenges that can arise when using TC in nursing homes to provide care for older adults while also providing information on how these challenges can be addressed. Furthermore, these findings provide guidance for further research to improve the care of residents in nursing homes from an ethical perspective.

On resource allocation in health care: The case of concierge medicine

Resource allocation generally involves a tension between efficiency and equity, particularly in health care. The growth in exclusive physician arrangements using non-linear prices is leading to consumer segmentation with theoretically ambiguous welfare implications. We study concierge medicine, in which physicians only provide care to patients paying a retainer fee. We find limited evidence of selection based on health and stronger evidence of selection based on income. Using a matching strategy that leverages the staggered adoption of concierge medicine, we find large spending increases and no average mortality effects for patients impacted by the switch to concierge medicine.

Racialized economic segregation and potentially preventable hospitalizations among Medicaid/CHIP-enrolled children

OBJECTIVE

To examine geographic variation in preventable hospitalizations among Medicaid/CHIP-enrolled children and to test the association between preventable hospitalizations and a novel measure of racialized economic segregation, which captures residential segregation within ZIP codes based on race and income simultaneously.

DATA SOURCES

We supplement claims and enrollment data from the Transformed Medicaid Statistical Information System (T-MSIS) representing over 12 million Medicaid/CHIP enrollees in 24 states with data from the Public Health Disparities Geocoding Project measuring racialized economic segregation.

STUDY DESIGN

We measure preventable hospitalizations by ZIP code among children. We use logistic regression to estimate the association between ZIP code-level measures of racialized economic segregation and preventable hospitalizations, controlling for sex, age, rurality, eligibility group, managed care plan type, and state.

DATA EXTRACTION METHODS

We include children ages 0-17 continuously enrolled in Medicaid/CHIP throughout 2018. We use validated algorithms to identify preventable hospitalizations, which account for characteristics of the pediatric population and exclude children with certain underlying conditions.

PRINCIPAL FINDINGS

Preventable hospitalizations vary substantially across ZIP codes, and a quarter of ZIP codes have rates exceeding 150 hospitalizations per 100,000 Medicaid-enrolled children per year. Preventable hospitalization rates vary significantly by level of racialized economic segregation: children living in the ZIP codes that have the highest concentration of low-income, non-Hispanic Black residents have adjusted rates of 181 per 100,000 children, compared to 110 per 100,000 for children in ZIP codes that have the highest concentration of high-income, non-Hispanic white residents (p < 0.01). This pattern is driven by asthma-related preventable hospitalizations.

CONCLUSIONS

Medicaid-enrolled children's risk of preventable hospitalizations depends on where they live, and children in economically and racially segregated neighborhoods-specifically those with higher concentrations of low-income, non-Hispanic Black residents-are at particularly high risk. It will be important to identify and implement Medicaid/CHIP and other policies that increase access to high-quality preventive care and that address structural drivers of children's health inequities.

Artificial intelligence in mobile health for skin cancer diagnostics at home (AIM HIGH): a pilot feasibility study

Background

Artificial intelligence (AI)-based mobile phone apps (mHealth) have the potential to streamline care for suspicious skin lesions in primary care. This study aims to investigate the conditions and feasibility of a study that incorporates an AI-based app in primary care and evaluates its potential impact.

Methods

We conducted a pilot feasibility study from November 22nd, 2021 to June 9th, 2022 with a mixed-methods design on implementation of an AI-based mHealth app for skin cancer detection in three primary care practices in the Netherlands (Rotterdam, Leiden and Katwijk). The primary outcome was the inclusion and successful participation rate of patients and general practitioners (GPs). Secondary outcomes were the reasons, facilitators and barriers for successful participation and the potential impact in both pathways for future sample size calculations. Patients were offered use of an AI-based mHealth app before consulting their GP. GPs assessed the patients blinded and then unblinded to the app. Qualitative data included observations and audio-diaries from patients and GPs and focus-groups and interviews with GPs and GP assistants.

Findings

Fifty patients were included with a median age of 52 years (IQR 33.5-60.3), 64% were female, and 90% had a light skin type. The average patient inclusion rate was 4-6 per GP practice per month and 84% (n = 42) successfully participated. Similarly, in 90% (n = 45 patients) the GPs also successfully completed the study. GPs never changed their working diagnosis, but did change their treatment plan (n = 5) based on the app's assessments. Notably, 54% of patients with a benign skin lesion and low risk rating, indicated that they would be reassured and cancel their GP visit with these results (p < 0.001).

Interpretation

Our findings suggest that studying implementation of an AI-based mHealth app for detection of skin cancer in the hands of patients or as a diagnostic tool used by GPs in primary care appears feasible. Preliminary results indicate potential to further investigate both intended use settings.

Funding

SkinVision B.V.

Determinants of referral for suspected coronary artery disease: a qualitative study based on decision thresholds

BACKGROUND

Chest pain is a frequent consultation issue in primary care, with coronary artery disease (CAD) being a serious potential cause. Primary care physicians (PCPs) assess the probability for CAD and refer patients to secondary care if necessary. Our aim was to explore PCPs' referral decisions, and to investigate determinants which influenced those decisions.

METHODS

PCPs working in Hesse, Germany, were interviewed in a qualitative study. We used 'stimulated recall' with participants to discuss patients with suspected CAD. With a sample size of 26 cases from nine practices we reached inductive thematic saturation. Interviews were audio-recorded, transcribed verbatim and analyzed by inductive-deductive thematic content analysis. For the final interpretation of the material, we used the concept of decision thresholds proposed by Pauker and Kassirer.

RESULTS

PCPs reflected on their decisions for or against a referral. Aside from patient characteristics determining disease probability, we identified general factors which can be understood as influencing the referral threshold. These factors relate to the practice environment, to PCPs themselves and to non-diagnostic patient characteristics. Proximity of specialist practice, relationship with specialist colleagues, and trust played a role. PCPs sometimes felt that invasive procedures were performed too easily. They tried to steer their patients through the system with the intent to avoid over-treatment. Most PCPs were unaware of guidelines but relied on informal local consensus, largely influenced by specialists. As a result, PCPs gatekeeping role was limited.

CONCLUSIONS

We could identify a large number of factors that impact referral for suspected CAD. Several of these factors offer possibilities to improve care at the clinical and system level. The threshold model proposed by Pauker and Kassirer was a useful framework for this kind of data analysis.

Clinician acceptability of an antibiotic prescribing knowledge support system for primary care: a mixed-method evaluation of features and context

BACKGROUND

Overprescribing of antibiotics is a major concern as it contributes to antimicrobial resistance. Research has found highly variable antibiotic prescribing in (UK) primary care, and to support more effective stewardship, the BRIT Project (Building Rapid Interventions to optimise prescribing) is implementing an eHealth Knowledge Support System. This will provide unique individualised analytics information to clinicians and patients at the point of care. The objective of the current study was to gauge the acceptability of the system to prescribing healthcare professionals and highlight factors to maximise intervention uptake.

METHODS

Two mixed-method co-design workshops were held online with primary care prescribing healthcare professionals (n = 16). Usefulness ratings of example features were collected using online polls and online whiteboards. Verbal discussion and textual comments were analysed thematically using inductive (participant-centred) and deductive perspectives (using the Theoretical Framework of Acceptability).

RESULTS

Hierarchical thematic coding generated three overarching themes relevant to intervention use and development. Clinician concerns (focal issues) were safe prescribing, accessible information, autonomy, avoiding duplication, technical issues and time. Requirements were ease and efficiency of use, integration of systems, patient-centeredness, personalisation, and training. Important features of the system included extraction of pertinent information from patient records (such as antibiotic prescribing history), recommended actions, personalised treatment, risk indicators and electronic patient communication leaflets. Anticipated acceptability and intention to use the knowledge support system was moderate to high. Time was identified as a focal cost/ burden, but this would be outweighed if the system improved patient outcomes and increased prescribing confidence.

CONCLUSION

Clinicians anticipate that an eHealth knowledge support system will be a useful and acceptable way to optimise antibiotic prescribing at the point of care. The mixed method workshop highlighted issues to assist person-centred eHealth intervention development, such as the value of communicating patient outcomes. Important features were identified including the ability to efficiently extract and summarise pertinent information from the patient records, provide explainable and transparent risk information, and personalised information to support patient communication. The Theoretical Framework of Acceptability enabled structured, theoretically sound feedback and creation of a profile to benchmark future evaluations. This may encourage a consistent user-focused approach to guide future eHealth intervention development.

Association of Primary Care Visit Length With Potentially Inappropriate Prescribing

Importance

Time is a valuable resource in primary care, and physicians and patients consistently raise concerns about inadequate time during visits. However, there is little evidence on whether shorter visits translate into lower-quality care.

Objective

To investigate variations in primary care visit length and quantify the association between visit length and potentially inappropriate prescribing decisions by primary care physicians.

Design, Setting, and Participants

This cross-sectional study used data from electronic health record systems in primary care offices across the US to analyze adult primary care visits occurring in calendar year 2017. Analysis was conducted from March 2022 through January 2023.

Main Outcomes and Measures

Regression analyses quantified the association between patient visit characteristics and visit length (measured using time stamp data) and the association between visit length and potentially inappropriate prescribing decisions, including inappropriate antibiotic prescriptions for upper respiratory tract infections, coprescribing of opioids and benzodiazepines for painful conditions, and prescriptions that were potentially inappropriate for older adults (based on the Beers criteria). All rates were estimated using physician fixed effects and were adjusted for patient and visit characteristics.

Results

This study included 8 119 161 primary care visits by 4 360 445 patients (56.6% women) with 8091 primary care physicians; 7.7% of patients were Hispanic, 10.4% were non-Hispanic Black, 68.2% were non-Hispanic White, 5.5% were other race and ethnicity, and 8.3% had missing race and ethnicity. Longer visits were more complex (ie, more diagnoses recorded and/or more chronic conditions coded). After controlling for scheduled visit duration and measures of visit complexity, younger, publicly insured, Hispanic, and non-Hispanic Black patients had shorter visits. For each additional minute of visit length, the likelihood that a visit resulted in an inappropriate antibiotic prescription changed by -0.11 percentage points (95% CI, -0.14 to -0.09 percentage points) and the likelihood of opioid and benzodiazepine coprescribing changed by -0.01 percentage points (95% CI, -0.01 to -0.009 percentage points). Visit length had a positive association with potentially inappropriate prescribing among older adults (0.004 percentage points; 95% CI, 0.003-0.006 percentage points).

Conclusions and Relevance

In this cross-sectional study, shorter visit length was associated with a higher likelihood of inappropriate antibiotic prescribing for patients with upper respiratory tract infections and coprescribing of opioids and benzodiazepines for patients with painful conditions. These findings suggest opportunities for additional research and operational improvements to visit scheduling and quality of prescribing decisions in primary care.

Improving diagnosis: adding context to cognition

BACKGROUND

The environment in which clinicians provide care and think about their patients is a crucial and undervalued component of the diagnostic process.

CONTENT

In this paper, we propose a new conceptual model that links work conditions to clinician responses such as stress and burnout, which in turn impacts the quality of the diagnostic process and finally patient diagnostic outcomes. The mechanism for these interactions critically depends on the relationship between working memory (WM) and long-term memory (LTM), and ways WM and LTM interactions are affected by working conditions.

SUMMARY

We propose a conceptual model to guide interventions to improve work conditions, clinician reactions and ultimately diagnostic process, accuracy and outcomes.

OUTLOOK

Improving diagnosis can be accomplished if we are able to understand, measure and increase our knowledge of the context of care.

Evaluating a Prototype Clinical Decision Support Tool for Chronic Pain Treatment in Primary Care

OBJECTIVES

 The Chronic Pain Treatment Tracker (Tx Tracker) is a prototype decision support tool to aid primary care clinicians when caring for patients with chronic noncancer pain. This study evaluated clinicians' perceived utility of Tx Tracker in meeting information needs and identifying treatment options, and preferences for visual design.

METHODS

 We conducted 12 semi-structured interviews with primary care clinicians from four health systems in Indiana. The interviews were conducted in two waves, with prototype and interview guide revisions after the first six interviews. The interviews included exploration of Tx Tracker using a think-aloud approach and a clinical scenario. Clinicians were presented with a patient scenario and asked to use Tx Tracker to make a treatment recommendation. Last, participants answered several evaluation questions. Detailed field notes were collected, coded, and thematically analyzed by four analysts.

RESULTS

 We identified several themes: the need for clinicians to be presented with a comprehensive patient history, the usefulness of Tx Tracker in patient discussions about treatment planning, potential usefulness of Tx Tracker for patients with high uncertainty or risk, potential usefulness of Tx Tracker in aggregating scattered information, variability in expectations about workflows, skepticism about underlying electronic health record data quality, interest in using Tx Tracker to annotate or update information, interest in using Tx Tracker to translate information to clinical action, desire for interface with visual cues for risks, warnings, or treatment options, and desire for interactive functionality.

CONCLUSION

 Tools like Tx Tracker, by aggregating key information about past, current, and potential future treatments, may help clinicians collaborate with their patients in choosing the best pain treatments. Still, the use and usefulness of Tx Tracker likely relies on continued improvement of its functionality, accurate and complete underlying data, and tailored integration with varying workflows, care team roles, and user preferences.

Effect of Integrating Access to a Prescription Drug Monitoring Program Within the Electronic Health Record on the Frequency of Queries by Primary Care Clinicians: A Cluster Randomized Clinical Trial

Importance

Tools that are directly integrated with the electronic health record (EHR) workflow can reduce the hassle cost of certain guideline-concordant practices, such as querying a prescription drug monitoring program (PDMP) before prescribing opioids.

Objective

To investigate the effect of integrating access to a PDMP within the EHR on the frequency of program queries by primary care clinicians.

Design Settings and Participants

The PRINCE (Prescribing Interventions for Chronic Pain Using the Electronic Health Record) randomized trial used a factorial cluster design at the clinic level in 43 primary care clinics in Minnesota. In all, 309 clinicians participated; 161 clinicians were given EHR-integrated access to PDMP at the intervention clinics, and 148 clinicians had the usual access at the control clinics. The intervention went live on August 27, 2020, and data were collected through March 3, 2021.

Intervention

Single sign-on access to the Minnesota PDMP was integrated into the EHR, allowing clinicians to query a patient's controlled substance prescription and dispensing history as recorded in the Minnesota PDMP directly from the patient's EHR record without logging into a separate web portal. Additionally, the integration tool alerted clinicians and reminded them to review the PDMP if a patient had 3 or more opioid prescriptions in the past year and 1 or more in the past 6 months. Clinics in the control group did not receive access to the EHR-integrated PDMP tool; instead, these participants logged into the PDMP web portal separately.

Main Outcomes and Measures

Monthly PDMP query counts for primary care clinicians, overall and by modality (EHR-based, web-based, via a clinical delegate), adjusted for clinician characteristics, including type (physician, nurse practitioner, physician assistant), sex, and years in practice. Data were analyzed from August 2021 to May 2022.

Results

Of the 43 participating clinics with 309 clinicians, 21 clinics with 161 clinicians (102 [63.4%] women; 114 [70.8%] physicians; tenure, 10.6 [4.4] years) received the PDMP integration intervention. Baseline unadjusted monthly PDMP query rates for the average clinician were 6.6 (95% CI, 4.4-9.9) vs 8.8 (95% CI, 6.0-13.1) queries in the control vs the PDMP integration group, respectively. During the intervention, PDMP query rates for the average clinician were 6.9 (95% CI, 4.7-10.3) vs 14.8 (95% CI, 10.0-22.0) queries among the control vs the PDMP integration group, respectively. Compared with the control group, the EHR-integrated PDMP tool produced a 60% greater increase in the relative change in monthly PDMP queries (95% CI, 51%-70%). An increase in PDMP queries via the EHR-integrated PDMP tool drove this increase, while web-based and delegate queries declined by 39% more among the intervention compared with the control group (95% CI, 34%-43%).

Conclusions and Relevance

This cluster randomized clinical trial found that integrating access to the PDMP in the EHR increased PDMP-querying rates, suggesting that direct access reduced hassle costs and can dramatically improve adherence to guideline-concordant care practices among primary care clinicians.

Trial Registration

ClinicalTrials.gov Identifier: NCT04601506.

Physicians under Pressure: Evidence from Antibiotics Prescribing in England

BACKGROUND

Many physicians are experiencing increasing demands from both their patients and society. Evidence is scarce on the consequences of the pressure on physicians' decision making. We present a theoretical framework and predict that increasing pressure may make physicians disregard societal welfare when treating patients.

SETTING

We test our prediction on general practitioners' antibiotic-prescribing choices. Because prescribing broad-spectrum antibiotics does not require microbiological testing, it can be performed more quickly than prescribing for narrow-spectrum antibiotics and is therefore often preferred by the patient. In contrast, from a societal perspective, inappropriate prescribing of broad-spectrum antibiotics should be minimized as it may contribute to antimicrobial resistance in the general population.

METHODS

We combine longitudinal survey data and administrative data from 2010 to 2017 to create a balanced panel of up to 1072 English general practitioners (GPs). Using a series of linear models with GP fixed effects, we estimate the importance of different sources of pressure for GPs' prescribing.

RESULTS

We find that the percentage of broad-spectrum antibiotics prescribed increases by 6.4% as pressure increases on English GPs. The link between pressure and prescribing holds for different sources of pressure.

CONCLUSIONS

Our findings suggest that there may be societal costs of physicians working under pressure. Policy makers need to take these costs into account when evaluating existing policies as well as when introducing new policies affecting physicians' work pressure. An important avenue for further research is also to determine the underlying mechanisms related to the different sources of pressure.JEL-code: I11, J28, J45.

HIGHLIGHTS

Many physicians are working under increasing pressure.We test the importance of pressure on physicians' prescribing of antibiotics.The prescribed rate of broad-spectrum antibiotics increases with pressure.Policy makers should be aware of the societal costs of pressured physicians.[Formula: see text].

Regional market factors and patient experience in primary care

OBJECTIVES

To evaluate the association between regional market factors and experience with patient-provider communication in primary care services of safety net hospitals.

STUDY DESIGN

A retrospective cohort study with 933,407 patient experience survey respondents from 128 Veterans Health Administration (VHA) hospitals between fiscal years 2013 and 2016.

METHODS

Patient responses on 5 patient-provider communication questions were used to evaluate quality of care. Six regional market factors were used to characterize veterans' health care insurance coverage and affluence. A logistic regression was used to examine changes in individual-level patient-provider communication experience when regional market factors increase or decrease the demand for VHA primary care services.

RESULTS

Our findings supported our hypothesis that changes in regional market factors shift patient demand for VHA care and affect patient-provider communication measured by patient experience surveys. The adjusted odds ratio (AOR) of positive patient-provider communication was associated with a regional increase (first to third quartile) of employer-sponsored insurance (AOR, 1.028; 95% CI, 1.001-1.055) and a decrease (third to first quartile) in the veterans' unemployment rate (AOR, 0.966; 95% CI, 0.944-0.990). Higher primary care capacity (first to third quartile) was also associated with positive patient-provider communication (AOR, 1.050; 95% CI, 1.018-1.082).

CONCLUSIONS

Findings from this study raise concerns that safety net hospitals could be unfairly penalized by value-based payment programs and Medicare Hospital Compare. Such policies and programs could improve resource allocation by accounting for regional market factors before acting on quality of care measures.