Addressing the unique challenges of inner-city practice: a direct observation study of inner-city, rural, and suburban family practices

Perceived discrimination in primary care: Does Payer mix matter?

INTRODUCTION

Previous literature has explored patient perceptions of discrimination by race and insurance status, but little is known about whether the payer mix of the primary care clinic (i.e., that is majority public insurance vs. majority private insurance clinics) influences patient perceptions of race- or insurance-based discrimination.

METHODS

Between 2015-2017, we assessed patient satisfaction and perceived race- and insurance-based discrimination using a brief, anonymous post-clinic visit survey.

RESULTS

Participants included 3,721 patients from seven primary care clinics-three public clinics and four private clinics. Results from unadjusted logistic regression models suggest higher overall reports of race- and insurance-based discrimination in public clinics compared with private clinics. In mulvariate analyses, increasing age, Black race, lower education and Medicaid insurance were associated with higher odds of reporting race- and insurance-based discrimination in both public and private settings.

CONCLUSION

Reports of race and insurance discrimination are higher in public clinics than private clinics. Sociodemographic variables, such as age, Black race, education level, and type of insurance also influence reports of race- and insurance-based discrimination in primary care.

Reasons for encounter and health problems managed by general practitioners in the rural areas of Beijing, China: A cross-sectional study

OBJECTIVE

The purpose of this study was to describe the patients' reasons for encounter (RFE) and health problems managed by general practitioners (GPs) in the rural areas of Beijing to provide evidences for health services planning and GPs training.

METHODS

This study was conducted at 14 community health service centers (CHSCs) in 6 suburban districts of Beijing, using a multistage sampling method. A total of 100 GPs was selected from the study sites. A self-designed data collection form was developed on the basis of Subjective-Objective-Assessment-Plan (SOAP), including patient characteristics, RFEs, health problems, interventions, and consultation length. Each GP recorded and coded their 100 consecutive patients' RFEs and health problems with the International Classification of Primary Care, 2nd version (ICPC-2). Descriptive statistics were employed to describe the distribution of RFE and health problems. Student t-test and analysis of variance were used to compare the differences of mean number of RFE or health problems per encounter by patient characteristics.

RESULTS

A total of 10,000 patient encounters with 13,705 RFEs and 15,460 health problems were recorded. The RFEs and health problems were mainly distributed in respiratory, circulatory, musculoskeletal, endocrine, metabolic and nutritional, and digestive systems. Cough and hypertension were the most common RFE and health problem, respectively. With increased ages, the mean number of RFEs decreased and the mean number of health problems increased. Patients with Beijing medical insurance had less RFEs and more health problems than those in other cities (p<0.001). Patients who had visited the CHSC previously and signed contracts with the GP team had more health problems than those who had not (p<0.001).

CONCLUSIONS

These findings present a view of patients' demands and work contents of GPs in Beijing rural areas and can provide reference for health services planning and GPs training.

International variations in primary care physician consultation time: a systematic review of 67 countries

OBJECTIVE

To describe the average primary care physician consultation length in economically developed and low-income/middle-income countries, and to examine the relationship between consultation length and organisational-level economic, and health outcomes.

DESIGN AND OUTCOME MEASURES

This is a systematic review of published and grey literature in English, Chinese, Japanese, Spanish, Portuguese and Russian languages from 1946 to 2016, for articles reporting on primary care physician consultation lengths. Data were extracted and analysed for quality, and linear regression models were constructed to examine the relationship between consultation length and health service outcomes.

RESULTS

One hundred and seventy nine studies were identified from 111 publications covering 28 570 712 consultations in 67 countries. Average consultation length differed across the world, ranging from 48 s in Bangladesh to 22.5 min in Sweden. We found that 18 countries representing about 50% of the global population spend 5 min or less with their primary care physicians. We also found significant associations between consultation length and healthcare spending per capita, admissions to hospital with ambulatory sensitive conditions such as diabetes, primary care physician density, physician efficiency and physician satisfaction.

CONCLUSION

There are international variations in consultation length, and it is concerning that a large proportion of the global population have only a few minutes with their primary care physicians. Such a short consultation length is likely to adversely affect patient healthcare and physician workload and stress.

Rural Women Family Physicians: Strategies for Successful Work-Life Balance

PURPOSE

Women family physicians experience challenges in maintaining work-life balance while practicing in rural communities. We sought to better understand the personal and professional strategies that enable women in rural family medicine to balance work and personal demands and achieve long-term career satisfaction.

METHODS

Women family physicians practicing in rural communities in the United States were interviewed using a semistructured format. Interviews were recorded, professionally transcribed, and analyzed using an immersion and crystallization approach, followed by detailed coding of emergent themes.

RESULTS

The 25 participants described a set of strategies that facilitated successful work-life balance. First, they used reduced or flexible work hours to help achieve balance with personal roles. Second, many had supportive relationships with spouses and partners, parents, or other members of the community, which facilitated their ability to be readily available to their patients. Third, participants maintained clear boundaries around their work lives, which helped them to have adequate time for parenting, recreation, and rest.

CONCLUSIONS

Women family physicians can build successful careers in rural communities, but supportive employers, relationships, and patient approaches provide a foundation for this success. Educators, employers, communities, and policymakers can adapt their practices to help women family physicians thrive in rural communities.

The length and content of general practice consultation in two urban districts of Beijing: a preliminary observation study

Background

Community health service center (CHSC) and community health service station (CHSS) are the main institutions where general practitioners (GPs) deliver primary care in the urban area of China. Motivated by incentive policies, visits to community health service institutions (CHSIs) increased gradually in recent years, but concerns had been raised on the quality of general practice consultation. This is a preliminary study aimed to investigate the existing problems of general practice consultation in Beijing and provide practical evidence for developing relevant policies.

Methods

Six GPs from 2 CHSCs and 3 CHSSs were selected by purposive sampling. The GPs were observed for 4 or 5 consecutive days during January 2013 to March 2013. The length and content of consultations were recorded in structured observation forms. Quantitative description was applied to describe the median, percentage and frequency of variables.

Results

A total of 1135 consultations were observed. The most frequent reason for consultations was specific prescription (61.6%), followed by presenting symptoms (20.7%), check-up (9.1%), counseling (5.4%), transfusion & injection (3.0%) and sickness certificate (0.2%). The median consultation length of all consultations was 2.0 minutes. The GPs prescribed in 81.0% of the consultations, on the other hand, history taking, physical examination, explanation of illness and health education only took place in 27.0%, 28.0%, 21.9% and 17.7% of the consultations respectively.

Conclusions

The adequacy of consultation length in CHSIs is in doubt. Most patients visited the CHSIs for prescription renewal. Health promotion e.g. health education are not adequately provided in consultations. The quality of general practice consultations was jeopardized by the large amount of patient flow for medicine renewal. Policies should be adjusted to reduce unnecessary consultations. Further studies are in need to evaluate the outcome and influencing factors of general practice consultation in China.

Being overburdened and medically underserved: assessment of this double disparity for populations in the state of Maryland

BACKGROUND

Environmental justice research has shown that many communities of color and low-income persons are differentially burdened by noxious land uses including Toxic Release Inventory (TRI) facilities. However, limited work has been performed to assess how these populations tend to be both overburdened and medically underserved. We explored this "double disparity" for the first time in Maryland.

METHODS

We assessed spatial disparities in the distribution of TRI facilities in Maryland across varying levels of sociodemographic composition using 2010 US Census Health Professional Shortage Area (HPSA) data. Univariate and multivariate regression in addition to geographic information systems (GIS) were used to examine relationships between sociodemographic measures and location of TRI facilities. Buffer analysis was also used to assess spatial disparities. Four buffer categories included: 1) census tracts hosting one or more TRI facilities; 2) tracts located more than 0 and up to 0.5 km from the closest TRI facility; 3) tracts located more than 0.5 km and up to 1 km from a TRI facility; and 4) tracts located more than 1 km and up to 5 km from a TRI facility.

RESULTS

We found that tracts with higher proportions of non-white residents and people living in poverty were more likely to be closer to TRI facilities. A significant increase in income was observed with an increase in distance between a census tract and the closest TRI facility. In general, percent non-white was higher in HPSA tracts that host at least one TRI facility than in non-HPSA tracts that host at least one TRI facility. Additionally, percent poverty, unemployment, less than high school education, and homes built pre-1950 were higher in HPSA tracts hosting TRI facilities than in non-HPSA tracts hosting TRI facilities.

CONCLUSIONS

We found that people of color and low-income groups are differentially burdened by TRI facilities in Maryland. We also found that both low-income groups and persons without a high school education are both overburdened and medically underserved. The results of this study provide insight into how state agencies can better address the double disparity of disproportionate environmental hazards and limited access to health care resources facing vulnerable communities in Maryland.

Patient-centered care: the influence of patient and resident physician gender and gender concordance in primary care

BACKGROUND

Patient-centered care (PCC) is thought to significantly influence the process of care and its outcomes and has been identified as part of a comprehensive strategy for improving our nation's healthcare delivery system. Patient and physician gender, as well as gender concordance, may influence the provision of PCC.

METHODS

Patients (315 women, 194 men) were randomized to care by primary care resident physicians (48 women, 57 men). Sociodemographic information, history of health risk behaviors (tobacco use, alcoholism, and obesity), and self-reported global pain and health status were collected before the first visit. That visit and subsequent patient visits to the primary care physician (PCP) were videotaped during the year-long study period. PCC was measured by coding all videotapes using a modified version of the Davis Observation Code.

RESULTS

No significant gender differences in PCC were found between the male and female patients; however, female physicians provided increased PCC to their patients. The greatest amount of PCC was seen in the female patient-female physician gender dyad. Regression analyses, controlling for other patient variables, confirmed that female concordant dyads were associated with a greater amount of PCC. There was no significant relationship for the male patient-male physician concordance (vs. disconcordance).

CONCLUSIONS

These findings highlight the influence of gender in the process of care and provision of PCC. Gender concordance in female patient-female physician dyads demonstrated significantly more PCC. Further research in other clinical settings using other measures of PCC is needed. A public mandate to provide care that is patient-centered has implications for medical education.

So much to do, so little time: care for the socially disadvantaged and the 15-minute visit

There is so much to do in primary care, and so little time to do it. During 15-minute visits, physicians are expected to form partnerships with patients and their families, address complex acute and chronic biomedical and psychosocial problems, provide preventive care, coordinate care with specialists, and ensure informed decision making that respects patients' needs and preferences. This is a challenging task during straightforward visits, and it is nearly impossible when caring for socially disadvantaged patients with complex biomedical and psychosocial problems and multiple barriers to care. Consider the following scenario.

Framework for primary care organizations: the importance of a structural domain

Purpose

Conceptual frameworks for primary care have evolved over the last 40 years, yet little attention has been paid to the environmental, structural and organizational factors that facilitate or moderate service delivery. Since primary care is now of more interest to policy makers, it is important that they have a comprehensive and balanced conceptual framework to facilitate their understanding and appreciation. We present a conceptual framework for primary care originally developed to guide the measurement of the performance of primary care organizations within the context of a large mixed-method evaluation of four types of models of primary care in Ontario, Canada.

Methods

The framework was developed following an iterative process that combined expert consultation and group meetings with a narrative review of existing frameworks, as well as trends in health management and organizational theory.

Results

Our conceptual framework for primary care has two domains: structural and performance. The structural domain describes the health care system, practice context and organization of the practice in which any primary care organization operates. The performance domain includes features of health care service delivery and technical quality of clinical care.

Conclusion

As primary care evolves through demonstration projects and reformed delivery models, it is important to evaluate its structural and organizational features as these are likely to have a significant impact on performance.

The Value Of Electronic Health Records In Community Health Centers: Policy Implications

This paper analyzes the costs and benefits of electronic health records (EHRs) in six community health centers (CHCs) that serve disadvantaged patients. EHR-related benefits for most study CHCs did not pay for ongoing EHR costs, yet quality improvement (QI) was substantial. Compared to private practices, CHCs cannot use EHRs to increase visit coding levels and revenues, yet they likely use EHRs more aggressively for QI, which raises equity questions. The evidence suggests that policies are needed that help CHCs to afford EHRs and produce more EHR-related QI gains, including through grants and QI performance rewards.

Health disparities based on socioeconomic inequities: implications for urban health care

Health is unevenly distributed across socioeconomic status. Persons of lower income, education, or occupational status experience worse health and die earlier than do their better-off counterparts. This article discusses these disparities in the context of urban medical practice. The article begins with a discussion of the complex relationship among socioeconomic status, race, and health in the United States. It highlights the effects of institutional, individual, and internalized racism on the health of African Americans, including the insidious consequences of residential segregation and concentrated poverty. Next, the article reviews health disparities based on socioeconomic status across the life cycle, beginning in fetal health and ending with disparities among the elderly. Potential explanations for these socioeconomic-based disparities are addressed, including reverse causality (e.g., being poor causes lower socioeconomic status) and confounding by genetic factors. The article underscores social causation as the primary explanation for health disparities and highlights the cumulative effects of social disadvantage across stages of the life cycle and across environments (e.g., fetal, family, educational, occupational, and neighborhood). The article concludes with a discussion of the implications of health disparities for the practice of urban medicine, including the role that concentration of disadvantage plays among patients and practice sites and the need for quality improvement to mitigate these disparities.

Gender Differences in Time Spent during Direct Observation of Doctor-Patient Encounters

BACKGROUND

Despite increasing recognition of women's health needs, little is known about how primary care physicians spend time with women. Therefore, we examined differences in time use and preventive service delivery during outpatient visits by male and female patients.

METHODS

As part of a multimethod study of 138 family physicians, 3384 outpatient visits by adults were directly observed, medical records were reviewed, and patient surveys were performed. Time use was assessed by the Davis Observation Code, which classifies every 15 seconds into 20 behavioral categories. Receipt of health habit counseling recommended by the U.S. Preventive Services Task Force was assessed by direct observation, and eligibility was determined by chart review. Logistic regression and multivariate analysis of variance (ANOVA) were used to compare time use and preventive service delivery in visits by women vs. men.

RESULTS

Sixty-four percent of adult visits were from women. Women reported poorer physical health, had higher rates of anxiety (12.5% vs. 7.4% in men), and depression (21.9% vs. 8.4% in men), a higher percent of visits for well care (10.2% vs. 8.8% in men), and more drugs prescribed (64.8% vs. 61% in men) and raised more emotional issues than men (14.7% vs. 7.5%). After controlling for visit and patients characteristics, visits by women had a higher percent of time spent on physical examination, structuring the intervention, patient questions, screening, and emotional counseling. Visits by men involved a higher percent of time spent on procedures and health behavior counseling. More eligible men than women received exercise, diet, and substance abuse counseling. Patients of female physicians exhibited gender differences in only one category of how time was spent (substance abuse), whereas among patients of male physicians, gender differences were noted in 10 of the 20 categories.

CONCLUSIONS

Outpatient visits by women differ from those of men in ways that reflect women's unique healthcare needs but also raise concern about unequal delivery of health habit counseling for diet and exercise.