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Mahlknecht A, Engl A, Barbieri V, Bachler H, Obwegeser A, Piccoliori G, Wiedermann CJ. Attitudes towards career choice and general practice: a cross-sectional survey of medical students and residents in Tyrol, Austria. BMC MEDICAL EDUCATION 2024; 24:294. [PMID: 38491385 PMCID: PMC10943776 DOI: 10.1186/s12909-024-05205-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 02/21/2024] [Indexed: 03/18/2024]
Abstract
BACKGROUND The global primary healthcare workforce is declining, leading to a shortage of general practitioners. Although various educational models aim to increase interest in general practice, effective interventions are limited. The reasons for this low appeal among medical graduates remain unclear. METHODS This cross-sectional study surveyed medical students' and residents' attitudes towards general practice in Tyrol, Austria. The online questionnaire addressed professional values, general practice-related issues, personal professional intentions, and demographics. Data analysis employed chi-square tests and multivariate logistic regression to explore predictors of interest in general practice. RESULTS The study included 528 students and 103 residents. Key values identified were stable positions, assured income, and work-family reconciliation. General practice was recognised for long-term patient relationships and patient contact, with students attributing more positive work-environmental characteristics and higher reputation to it than residents. Few participants (students: 3.2%, residents: 11.7%) had opted for general practice; about half were considering it as career option. Reasons not to choose general practice were preferences for other specialties, intrinsic characteristics of general practice, workload, insufficient time for the patients, financial pressures, low reputation, and perceived mediocre training quality. Predictors of interest in general practice included perception of independent decision-making, importance of work-family balance (students), better practical experiences in general practice during medical school (students and residents), younger age, and perceiving general practice as offering a promising future (residents). Both groups felt underprepared by medical school and/or general practice training for general practice roles. The attractiveness of specialist medicine over general practice was related to clearer content boundaries, better career opportunities, and higher incomes. CONCLUSIONS According to these results, measures to improve attractiveness of general practice should focus on (i) high-quality undergraduate education including practical experiences, and (ii) on ensuring professional autonomy, work-family reconciliation, and job stability. Efforts to encourage more graduates to pursue this essential healthcare sector are crucial for strengthening primary healthcare and public health services. TRIAL REGISTRATION The study has not been registered as it did not include a direct medical intervention on human participants.
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Affiliation(s)
- Angelika Mahlknecht
- Institute of General Practice and Public Health, College of Health Care Professions, Lorenz-Boehler-street 13, Bolzano, 39100, Italy.
| | - Adolf Engl
- Institute of General Practice and Public Health, College of Health Care Professions, Lorenz-Boehler-street 13, Bolzano, 39100, Italy
| | - Verena Barbieri
- Institute of General Practice and Public Health, College of Health Care Professions, Lorenz-Boehler-street 13, Bolzano, 39100, Italy
| | - Herbert Bachler
- Institute of General Practice, Medical University Innsbruck, Christoph-Probst-square 1, Innsbruck, 6020, Austria
| | - Alois Obwegeser
- Department of Neurosurgery, University Hospital of Innsbruck, Anich-street 35, Innsbruck, 6020, Austria
| | - Giuliano Piccoliori
- Institute of General Practice and Public Health, College of Health Care Professions, Lorenz-Boehler-street 13, Bolzano, 39100, Italy
| | - Christian J Wiedermann
- Institute of General Practice and Public Health, College of Health Care Professions, Lorenz-Boehler-street 13, Bolzano, 39100, Italy.
- UMIT - Private University for Health Sciences, Medical Informatics and Technology - Tyrol, Eduard- Wallnöfer-center 1, Hall in Tirol, 6060, Austria.
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Obe DPG. General practice - the integrating discipline. Br J Gen Pract 2023; 73:388-390. [PMID: 37652723 PMCID: PMC10471325 DOI: 10.3399/bjgp23x734697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/02/2023] Open
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Bujold M, Pluye P, Légaré F. Decision-making and related outcomes of patients with complex care needs in primary care settings: a systematic literature review with a case-based qualitative synthesis. BMC PRIMARY CARE 2022; 23:279. [PMID: 36352376 PMCID: PMC9644584 DOI: 10.1186/s12875-022-01879-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Accepted: 10/07/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND In primary care, patients increasingly face difficult decisions related to complex care needs (multimorbidity, polypharmacy, mental health issues, social vulnerability and structural barriers). There is a need for a pragmatic conceptual model to understand decisional needs among patients with complex care needs and outcomes related to decision. We aimed to identify types of decisional needs among patients with complex care needs, and decision-making configurations of conditions associated with decision outcomes. METHODS We conducted a systematic mixed studies review. Two specialized librarians searched five bibliographic databases (Medline, Embase, PsycINFO, CINAHL and SSCI). The search strategy was conducted from inception to December 2017. A team of twenty crowd-reviewers selected empirical studies on: (1) patients with complex care needs; (2) decisional needs; (3) primary care. Two reviewers appraised the quality of included studies using the Mixed Methods Appraisal Tool. We conducted a 2-phase case-based qualitative synthesis framed by the Ottawa Decision Support Framework and Gregor's explicative-predictive theory type. A decisional need case involved: (a) a decision (what), (b) concerning a patient with complex care needs with bio-psycho-social characteristics (who), (c) made independently or in partnership (how), (d) in a specific place and time (where/when), (e) with communication and coordination barriers or facilitators (why), and that (f) influenced actions taken, health or well-being, or decision quality (outcomes). RESULTS We included 47 studies. Data sufficiency qualitative criterion was reached. We identified 69 cases (2997 participants across 13 countries) grouped into five types of decisional needs: 'prioritization' (n = 26), 'use of services' (n = 22), 'prescription' (n = 12), 'behavior change' (n = 4) and 'institutionalization' (n = 5). Many decisions were made between clinical encounters in situations of social vulnerability. Patterns of conditions associated with decision outcomes revealed four decision-making configurations: 'well-managed' (n = 13), 'asymmetric encounters' (n = 21), 'self-management by default' (n = 8), and 'chaotic' (n = 27). Shared decision-making was associated with positive outcomes. Negative outcomes were associated with independent decision-making. CONCLUSION Our results could extend decision-making models in primary care settings and inform subsequent user-centered design of decision support tools for heterogenous patients with complex care needs.
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Affiliation(s)
- Mathieu Bujold
- Department of Management, Evaluation and Health Policy, School of Public Health, Université de Montréal, Montreal, Canada.
- Department of Family Medicine, McGill University, Montreal, Canada.
| | - Pierre Pluye
- Department of Family Medicine, McGill University, Montreal, Canada
| | - France Légaré
- Department of Family Medicine and Emergency Medicine, Université Laval, Quebec City, Canada
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Affiliation(s)
- Ami Schattner
- The Faculty of Medicine, Hebrew University and Hadassah Medical School, Jerusalem 9112102, Israel
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Young RA, Nelson MJ, Castellon RE, Martin CM. Improving quality in a complex primary care system-An example of refugee care and literature review. J Eval Clin Pract 2021; 27:1018-1026. [PMID: 32596835 DOI: 10.1111/jep.13430] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 05/15/2020] [Accepted: 05/18/2020] [Indexed: 12/11/2022]
Abstract
RATIONALE, AIMS AND OBJECTIVES Applying traditional industrial quality improvement (QI) methodologies to primary care is often inappropriate because primary care and its relationship to the healthcare macrosystem has many features of a complex adaptive system (CAS) that is particularly responsive to bottom-up rather than top-down management approaches. We report on a demonstration case study of improvements made in the Family Health Center (FHC) of the JPS Health Network in a refugee patient population that illustrate features of QI in a CAS framework as opposed to a traditional QI approach. METHODS We report on changes in health system utilization by new refugee patients of the FHC from 2016 to 2017. We review the literature and summarize relevant theoretical understandings of quality management in complex adaptive systems as it applies to this case example. RESULTS Applying CAS principles in the FHC, utilization of the Emergency Department and Urgent Care Center by newly arrived refugee patients before their first clinic visit was reduced by more than half (total visits decreased from 31%-14% of the refugee patients). Our review of the literature demonstrates that traditional algorithmic top-down QI processes are most often unsuccessful in improving even a few single-disease metrics, and increases clinician burnout and penalizes clinicians who care for vulnerable patients. Improvement in a CAS occurs when front-line clinicians identify care gaps and are given the flexibility to learn and self-organize to enable new care processes to emerge, which are created from bottom-up leadership that utilize existing interdependencies and interact with the top levels of the organization through intelligent top-down causation. We give examples of early adapters who are better applying the principles of CAS change to their QI efforts. CONCLUSIONS Meaningful improvement in primary care is more likely achieved when the impetus to implement change shifts from top-down to bottom-up.
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Affiliation(s)
- Richard A Young
- JPS Hospital Family Medicine Residency Program, Fort Worth, Texas, USA
| | - Mark J Nelson
- JPS Hospital Family Medicine Residency Program, Fort Worth, Texas, USA
| | | | - Carmel M Martin
- Department of Medicine, Nursing and Allied Health, Monash University/Monash Health, Clayton, Victoria, Australia
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Sang H, González-Vallejo C, Zhao J, Long R. Is low cost really conducive to primary care utilisation: An empirical analysis of community health centers in China. HEALTH & SOCIAL CARE IN THE COMMUNITY 2021; 29:e163-e173. [PMID: 33386777 DOI: 10.1111/hsc.13262] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Revised: 11/28/2020] [Accepted: 12/07/2020] [Indexed: 06/12/2023]
Abstract
Despite community health centers (CHCs) having many potential benefits, their utilisation rate is still low in urban China. Using the health belief model, the study conducted cross-sectional survey to examine factors that affected individuals' intentions to use primary care services in China. This study on 942 participants from Shanghai revealed that low cost had insignificant effect on the choice of CHCs once other key factors were accounted for. Older age, greater perceived susceptibility to contracting common diseases and more benefits of individualised care greatly increased the likelihood of using primary care services. Perceived low competencies of medical personnel along with outdated medical facilities had significant negative relationships with the intention of choosing CHCs. Based on these findings, some policy recommendations are proposed such as promoting education on prevalence of common diseases, recruiting qualified medical personnel, increasing professional training and cooperation, updating medical facilities, and offering high-quality individualised care in order to improve efficiency of primary care utilisation.
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Affiliation(s)
- Hui Sang
- School of Management, Shanghai University of International Business and Economics, Shanghai, China
| | | | - Jing Zhao
- Department of Marketing and Tourism Management, Wuhan University, Wuhan, China
| | - Rui Long
- School of Management, Shanghai University of International Business and Economics, Shanghai, China
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Nyoni CN, Grobler C, Botma Y. Towards Continuing Interprofessional Education: Interaction patterns of health professionals in a resource-limited setting. PLoS One 2021; 16:e0253491. [PMID: 34242240 PMCID: PMC8270436 DOI: 10.1371/journal.pone.0253491] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Accepted: 06/04/2021] [Indexed: 11/18/2022] Open
Abstract
There are challenges related to collaboration among health professionals in resource-limited settings. Continuing Interprofessional Education initiatives grounded on workplace dynamics, structure and the prevailing attitudes and biases of targeted health professionals may be a vehicle to develop collaboration among health professionals. Workplace dynamics are revealed as health professionals interact. We argue that insights into the interaction patterns of health professionals in the workplace could provide guidance for improving the design and value of CIPE initiative. The study was conducted through rapid ethnography and data were collected from non-participant observations. The data were transcribed and analysed through an inductive iterative process. Appropriate ethical principles were applied throughout the study. Three themes emerged namely “Formed professional identities influencing interprofessional interaction”, “Diversity in communication networks and approaches” and “Professional practice and care in resource limited contexts”. This study revealed poor interaction patterns among health professionals within the workplace. These poor interaction patterns were catalyzed by the pervasive professional hierarchy, the protracted health professional shortages, limited understanding of professional roles and the lack of a common language of communication among the health professionals. Several recommendations were made regarding the design and development of Continuing Interprofessional Education initiatives for resource-limited settings.
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Affiliation(s)
- Champion N. Nyoni
- School of Nursing, University of the Free State, Bloemfontein, South Africa
- * E-mail:
| | - Cecilna Grobler
- School of Nursing, University of the Free State, Bloemfontein, South Africa
| | - Yvonne Botma
- School of Nursing, University of the Free State, Bloemfontein, South Africa
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Measuring the complexity of general practice consultations: a Delphi and cross-sectional study in English primary care. Br J Gen Pract 2021; 71:e423-e431. [PMID: 33824162 PMCID: PMC8049201 DOI: 10.3399/bjgp.2020.0486] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Accepted: 11/13/2020] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND The complexity of general practice consultations may be increasing and varies in different settings. A measure of complexity is required to test these hypotheses. AIM To develop a valid measure of general practice consultation complexity applicable to routine medical records. DESIGN AND SETTING Delphi study to select potential indicators of complexity followed by a cross-sectional study in English general practices to develop and validate a complexity measure. METHOD The online Delphi study over two rounds identified potential indicators of consultation complexity. The cross-sectional study used an age-sex stratified random sample of patients and general practice face-to-face consultations from 2013/2014 in the Clinical Practice Research Datalink. The authors explored independent relationships between each indicator and consultation duration using mixed-effects regression models, and revalidated findings using data from 2017/2018. The proportion of complex consultations in different age-sex groups was assessed. RESULTS A total of 32 GPs participated in the Delphi study. The Delphi panel endorsed 34 of 45 possible complexity indicators after two rounds. After excluding factors because of low prevalence or confounding, 17 indicators were retained in the cross-sectional study. The study used data from 173 130 patients and 725 616 face-to-face GP consultations. On defining complexity as the presence of any of these 17 factors, 308 370 consultations (42.5%) were found to be complex. Mean duration of complex consultations was 10.49 minutes, compared to 9.64 minutes for non-complex consultations. The proportion of complex consultations was similar in males and females but increased with age. CONCLUSION The present consultation complexity measure has face and construct validity. It may be useful for research, management and policy, and for informing decisions about the range of resources needed in different practices.
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Lussier MT, Richard C, Binta Diallo F, Boivin N, Hudon C, Boustani É, Witteman H, Jbilou J. I am ready to see you now, Doctor! A mixed-method study of the Let's Discuss Health website implementation in Primary Care. Health Expect 2020; 24:243-256. [PMID: 33285012 PMCID: PMC8077096 DOI: 10.1111/hex.13158] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Revised: 10/05/2020] [Accepted: 10/26/2020] [Indexed: 11/30/2022] Open
Abstract
Background Let's Discuss Health (LDH) is a website that encourages patients to prepare their health‐care encounters by providing communication training, review of topics and questions that are important to them. Objective To describe LDH implementation during primary care (PC) visits for chronic illnesses. Methods Design: Descriptive mixed‐method study. Setting: 6 PC clinics. Participants: 156 patients and 51 health‐care providers (HCP). Intervention: LDH website implementation. Outcome Measures: Perceived quality and usefulness of LDH; perceived quality of HCP‐patient communication; patient activation; LDH integration in routine PC practices and barriers to its use. Results Patients reported a positive perception of the website in that it helped them to adopt an active role in the encounters; recall their visit agenda and reduce encounter‐related stress; feel more confident to ask questions, feel more motivated to prepare their future medical visits and improve their chronic illness management. However, a certain disconnect emerged between HCP and patient perceptions as to the value of LDH in promoting a sense of partnership and collaboration. The main barriers to the use of LDH are HCP lack of interest, limited access to technology, lack of time and language barriers. Conclusion Our findings indicate that it is advantageous for patients to prepare their medical encounters. However, the study needs to be replicated in other medical environments using larger and more diverse samples. Patient and Public Contribution Patient partners were involved in the conduct of this study.
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Affiliation(s)
- Marie-Thérèse Lussier
- Department of Family Medicine and Emergency Medicine, University of Montreal, Montreal, QC, Canada.,Laval Integrated Health and Social Services Centre (Centre de santé et des services sociaux de Laval), Groupe de recherche sur les transformations des pratiques cliniques et organisationnelles, Laval, QC, Canada
| | - Claude Richard
- Laval Integrated Health and Social Services Centre (Centre de santé et des services sociaux de Laval), Groupe de recherche sur les transformations des pratiques cliniques et organisationnelles, Laval, QC, Canada
| | - Fatoumata Binta Diallo
- Laval Integrated Health and Social Services Centre (Centre de santé et des services sociaux de Laval), Groupe de recherche sur les transformations des pratiques cliniques et organisationnelles, Laval, QC, Canada
| | - Nathalie Boivin
- École réseau de Science infirmière (ÉRSI), University of Moncton, Moncton, NB, Canada
| | - Catherine Hudon
- Department of Family Medicine and Emergency Medicine, University of Sherbrooke, Sherbrooke, QC, Canada
| | - Élie Boustani
- Department of Family Medicine and Emergency Medicine, University of Montreal, Montreal, QC, Canada
| | - Holly Witteman
- Department of Family Medicine and Emergency Medicine, Laval University, Laval, QC, Canada
| | - Jalila Jbilou
- Centre de formation médicale du Nouveau Brunswick, Université de Sherbrooke, École de psychologie, University of Moncton, Moncton, NB, Canada
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Aysola J, Xu C, Huo H, Werner RM. The Relationships Between Patient Experience and Quality and Utilization of Primary Care Services. J Patient Exp 2020; 7:1678-1684. [PMID: 33457630 PMCID: PMC7786755 DOI: 10.1177/2374373520924190] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
We lack knowledge on how patient-reported experience relates to both quality of care services and visit attendance in the primary care setting. Therefore, in a cross-sectional analysis of 8355 primary care patients from 22 primary care practices, we examined the associations between visit-triggered patient-reported experience measures and both (1) quality of care measures and (2) number of missed primary care appointment (no shows). Our independent variables included both overall patient experience and its subdomains. Our outcomes included the following measures: smoking cessation discussion, diabetes eye examination referral, mammography, colonoscopy screening, current smoking status (nonsmoker vs smoker), diabetes control Hemoglobin A1c (HbA1c [<8]), blood pressure control, cholesterol control Low Density Lipoprotein (LDL) among patients with diabetes (LDL < 100), and visit no shows 2 and 5 years after the index visit that triggered the completed patient-experience survey. We found that patient experience, while an important stand-alone metric of care quality, may not relate to clinical outcomes or process measures in the outpatient setting. However, patient-reported experiences with their primary care provider appear to influence their future visit attendance.
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Affiliation(s)
- Jaya Aysola
- Division of General Internal Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, PA, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, PA, USA
| | - Chang Xu
- Division of General Internal Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, PA, USA
| | - Hairong Huo
- Division of General Internal Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, PA, USA
| | - Rachel M Werner
- Division of General Internal Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, PA, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, PA, USA
- Crescenz VA Medical Center, Philadelphia, PA, USA
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Differences in the Complexity of Office Visits by Physician Specialty: NAMCS 2013-2016. J Gen Intern Med 2020; 35:1715-1720. [PMID: 32157646 PMCID: PMC7280404 DOI: 10.1007/s11606-019-05624-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Revised: 11/04/2019] [Accepted: 12/13/2019] [Indexed: 10/24/2022]
Abstract
BACKGROUND Specialty-to-specialty variation in use of outpatient evaluation and management service codes could lead to important differences in reimbursement among specialties. OBJECTIVE To compare the complexity of visits to physicians whose incomes are largely dependent on evaluation and management services to the complexity of visits to physicians whose incomes are largely dependent on procedures. DESIGN, SETTING, AND PARTICIPANTS We analyzed 53,670 established patient outpatient visits reported by physicians in the National Ambulatory Medical Care Survey (NAMCS) from 2013 to 2016. We defined high complexity visits as those with an above average number of diagnoses (> 2) and/or medications (> 3) listed We based our comparison on time intervals corresponding to typical outpatient evaluation and management times as defined by the Current Procedural Terminology Manual and specialty utilization of evaluation and management codes based on 2015 Medicare payments. MAIN OUTCOME AND MEASURES Proportion of complex visits by specialty category. KEY RESULTS We found significant differences in the content of similar-length office visits provided by different specialties. For level 4 established outpatient visits (99214), the percentage involving high diagnostic complexity ranged from 62% for internal medicine, 52% for family medicine/general practice, and 41% for neurology (specialties whose incomes are largely dependent on evaluation and management codes), to 34% for dermatology, 42% for ophthalmology, and 25% for orthopedic surgery (specialties whose incomes are more dependent on procedure codes) (p value of the difference < 0.001). High medication complexity was found in the following proportions of visits: internal medicine 56%, family medicine/general practice 49%, and neurology 43%, as compared with dermatology 33%, ophthalmology 30%, and orthopedic surgery 30% (p value of the difference < 0.001). CONCLUSION Within the same duration visits, specialties whose incomes depend more on evaluation and management codes on average addressed more clinical issues and managed more medications than specialties whose incomes are more dependent on procedures.
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Temte JL, Beasley JW, Holden RJ, Karsh BT, Potter B, Smith P, O'Halloran P. Relationship between number of health problems addressed during a primary care patient visit and clinician workload. APPLIED ERGONOMICS 2020; 84:103035. [PMID: 31983397 DOI: 10.1016/j.apergo.2019.103035] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Revised: 07/09/2019] [Accepted: 12/13/2019] [Indexed: 06/10/2023]
Abstract
INTRODUCTION Primary care is complex due to multiple health problems being addressed in each patient visit. Little is known about the effect of the number of problems per encounter (NPPE) on the resulting clinician workload (CWL), as measured using the National Aeronautics and Space Administration Task Load Index (NASA-TLX). METHODS We evaluated the relationship between NPPE and CWL across 608 adult patient visits, conducted by 31 clinicians, using hierarchical linear regression. Clinicians were interviewed about outlier visits to identify reasons for higher or lower than expected CWL. RESULTS Mean NPPE was 3.30 ± 2.0 (sd) and CWL was 47.6 ± 18.4 from a maximum of 100. Mental demand, time demand and effort accounted for 71.5% of CWL. After adjustment for confounders, each additional problem increased CWL by 3.9 points (P < 0.001). Patient, problem, environmental and patient-physician relationship factors were qualitatively identified from interviews as moderators of this effect. CONCLUSION CWL is positively related to NPPE. Several modifiable factors may enhance or mitigate this effect. Our findings have implications for using a Human Factors (HF) approach to managing CWL.
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Affiliation(s)
- Jonathan L Temte
- University of Wisconsin School of Medicine and Public Health, Department of Family Medicine and Community Health, 1100 Delaplaine Court, Madison, WI, 53715, USA.
| | - John W Beasley
- University of Wisconsin School of Medicine and Public Health, Department of Family Medicine and Community Health, 1100 Delaplaine Court, Madison, WI, 53715, USA; University of Wisconsin, Department of Industrial and Systems Engineering, 1415 Engineering Drive, Madison, WI, 53706, USA
| | - Richard J Holden
- Indiana University School of Medicine, Department of Medicine 545 Barnhill Dr., Emerson Hall 305, Indianapolis, IN, 46202, USA
| | - Ben-Tzion Karsh
- University of Wisconsin, Department of Industrial and Systems Engineering, 1415 Engineering Drive, Madison, WI, 53706, USA.
| | - Beth Potter
- University of Wisconsin School of Medicine and Public Health, Department of Family Medicine and Community Health, 1100 Delaplaine Court, Madison, WI, 53715, USA
| | - Paul Smith
- University of Wisconsin School of Medicine and Public Health, Department of Family Medicine and Community Health, 1100 Delaplaine Court, Madison, WI, 53715, USA
| | - Peggy O'Halloran
- Eau Claire City-County Health Department, 720 2nd Ave, Eau Claire, WI, 54703, USA
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Bugaj TJ, Valentini J, Miksch A, Schwill S. Work strain and burnout risk in postgraduate trainees in general practice: an overview. Postgrad Med 2019; 132:7-16. [PMID: 31570072 DOI: 10.1080/00325481.2019.1675361] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Primary care physicians (general practitioners (GPs)) are burdened for various reasons and are particularly affected by stress-related complaints and an increasing prevalence of burnout. Thus, the prevention of physician burnout has become a major interest for health care services. Although many studies have addressed this issue in recent years, little seems to be known about the work strain and burnout rates in GP trainees. Therefore the objective of this article is to review the psychosocial burden and relevant prevention strategies for GPs with a special emphasis on GP trainees. Regardless of the specialty, burnout is more prevalent among medical trainees and so-called 'early career' physicians than among the age-matched population. Accordingly, burnout seems to be frequent among GP trainees, although there is some evidence that there are fewer doctors working in general medicine who were already heavily burdened at the time of choosing their career. The sudden assumption of responsibility in patient care as well as the fear of showing imperfection in front of their supervisors, or lack of recognition from senior doctors, the medical team, or patients might be stressors typical to this career stage. GP trainees might also feel burdened by the new level of personal involvement and thus have to develop or increase their individual level of professionality to deal with the patients' medical and personal problems. In conclusion, interventions to promote physical and mental health of GP trainees are a necessity to ensure passionate GPs in the future and should therefore be integrated into any postgraduate training curriculum in general practice.
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Affiliation(s)
- T J Bugaj
- Department of General Internal Medicine and Psychosomatics, University Hospital Heidelberg, Heidelberg, Germany
| | - J Valentini
- Institute of General Practice and Interprofessional Care, University Hospital Tuebingen, Tuebingen, Germany
| | - A Miksch
- Department of General Practice and Health Services Research, University Hospital Heidelberg, Heidelberg, Germany
| | - S Schwill
- Department of General Practice and Health Services Research, University Hospital Heidelberg, Heidelberg, Germany
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Burnout Among Physicians, Advanced Practice Clinicians and Staff in Smaller Primary Care Practices. J Gen Intern Med 2018; 33:2138-2146. [PMID: 30276654 PMCID: PMC6258608 DOI: 10.1007/s11606-018-4679-0] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Revised: 07/06/2018] [Accepted: 08/29/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Burnout among primary care physicians, advanced practice clinicians (nurse practitioners and physician assistants [APCs]), and staff is common and associated with negative consequences for patient care, but the association of burnout with characteristics of primary care practices is unknown. OBJECTIVE To examine the association between physician-, APC- and staff-reported burnout and specific structural, organizational, and contextual characteristics of smaller primary care practices. DESIGN Cross-sectional analysis of survey data collected from 9/22/2015-6/19/2017. SETTING Sample of smaller primary care practices in the USA participating in a national initiative focused on improving the delivery of cardiovascular preventive services. PARTICIPANTS 10,284 physicians, APCs and staff from 1380 primary care practices. MAIN MEASURE Burnout was assessed with a validated single-item measure. KEY RESULTS Burnout was reported by 20.4% of respondents overall. In a multivariable analysis, burnout was slightly more common among physicians and APCs (physician vs. non-clinical staff, adjusted odds ratio [aOR] = 1.26; 95% confidence interval [CI], 1.05-1.49, APC vs. non-clinical staff, aOR = 1.34, 95% CI, 1.10-1.62). Other multivariable correlates of burnout included non-solo practice (2-5 physician/APCs vs. solo practice, aOR = 1.71; 95% CI, 1.35-2.16), health system affiliation (vs. physician/APC-owned practice, aOR = 1.42; 95%CI, 1.16-1.73), and Federally Qualified Health Center status (vs. physician/APC-owned practice, aOR = 1.36; 95%CI, 1.03-1.78). Neither the proportion of patients on Medicare or Medicaid, nor practice-level patient volume (patient visits per physician/APC per day) were significantly associated with burnout. In analyses stratified by professional category, practice size was not associated with burnout for APCs, and participation in an accountable care organization was associated with burnout for clinical and non-clinical staff. CONCLUSIONS Burnout is prevalent among physicians, APCs, and staff in smaller primary care practices. Members of solo practices less commonly report burnout, while members of health system-owned practices and Federally Qualified Health Centers more commonly report burnout, suggesting that practice level autonomy may be a critical determinant of burnout.
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Kolber MA, Rueda G, Sory JB. Modelling the impact of new patient visits on risk adjusted access at 2 clinics. J Eval Clin Pract 2018; 24:585-589. [PMID: 29878611 DOI: 10.1111/jep.12938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2017] [Revised: 03/29/2018] [Accepted: 04/02/2018] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To evaluate the effect new outpatient clinic visits has on the availability of follow-up visits for established patients when patient visit frequency is risk adjusted. DATA SOURCES Diagnosis codes for patients from 2 Internal Medicine Clinics were extracted through billing data. STUDY DESIGN The HHS-HCC risk adjusted scores for each clinic were determined based upon the average of all clinic practitioners' profiles. These scores were then used to project encounter frequencies for established patients, and for new patients entering the clinic based on risk and time of entry into the clinics. PRINCIPAL FINDINGS A distinct mean risk frequency distribution for physicians in each clinic could be defined providing model parameters. Within the model, follow-up visit utilization at the highest risk adjusted visit frequencies would require more follow-up slots than currently available when new patient no-show rates and annual patient loss are included. Patients seen at an intermediate or lower visit risk adjusted frequency could be accommodated when new patient no-show rates and annual patient clinic loss are considered. CONCLUSIONS Value-based care is driven by control of cost while maintaining quality of care. In order to control cost, there has been a drive to increase visit frequency in primary care for those patients at increased risk. Adding new patients to primary care clinics limits the availability of follow-up slots that accrue over time for those at highest risk, thereby limiting disease and, potentially, cost control. If frequency of established care visits can be reduced by improved disease control, closing the practice to new patients, hiring health care extenders, or providing non-face to face care models then quality and cost of care may be improved.
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Affiliation(s)
- Michael A Kolber
- Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA.,University of Miami Miller School of Medicine, Miami, FL, USA
| | - Germán Rueda
- University of Miami Miller School of Medicine, Miami, FL, USA
| | - John B Sory
- University of Miami Miller School of Medicine, Miami, FL, USA
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Capturing complexity in clinician case-mix: classification system development using GP and physician associate data. BJGP Open 2018; 2:bjgpopen18X101277. [PMID: 30564699 PMCID: PMC6181080 DOI: 10.3399/bjgpopen18x101277] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Accepted: 08/14/2017] [Indexed: 01/10/2023] Open
Abstract
Background There are limited case-mix classification systems for primary care settings which are applicable when considering the optimal clinical skill mix to provide services. Aim To develop a case-mix classification system (CMCS) and test its impact on analyses of patient outcomes by clinician type, using example data from physician associates' (PAs) and GPs' consultations with same-day appointment patients. Design & setting Secondary analysis of controlled observational data from six general practices employing PAs and six matched practices not employing PAs in England. Method Routinely-collected patient consultation records (PA n = 932, GP n = 1154) were used to design the CMCS (combining problem codes, disease register data, and free text); to describe the case-mix; and to assess impact of statistical adjustment for the CMCS on comparison of outcomes of consultations with PAs and with GPs. Results A CMCS was developed by extending a system that only classified 18.6% (213/1147) of the presenting problems in this study's data. The CMCS differentiated the presenting patient's level of need or complexity as: acute, chronic, minor problem or symptom, prevention, or process of care, applied hierarchically. Combination of patient and consultation-level measures resulted in a higher classification of acuity and complexity for 639 (30.6%) of patient cases in this sample than if using consultation level alone. The CMCS was a key adjustment in modelling the study's main outcome measure, that is rate of repeat consultation. Conclusion This CMCS assisted in classifying the differences in case-mix between professions, thereby allowing fairer assessment of the potential for role substitution and task shifting in primary care, but it requires further validation.
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Martin CM. Complex adaptive systems approaches in health care-A slow but real emergence? J Eval Clin Pract 2018; 24:266-268. [PMID: 29589876 DOI: 10.1111/jep.12878] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Accepted: 12/19/2017] [Indexed: 11/30/2022]
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Fink W, Kamenski G, Konitzer M. Diagnostic protocols-A consultation tool still to be discovered. J Eval Clin Pract 2018; 24:293-300. [PMID: 28370977 PMCID: PMC5900935 DOI: 10.1111/jep.12710] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2016] [Accepted: 12/19/2016] [Indexed: 12/01/2022]
Abstract
RATIONALE Experienced primary care physicians handle most illnesses to everyone's satisfaction despite limited resources of time and means. However, cases can be multifaceted in that harmless-presenting symptoms may also be warning signals or an indicator of a health disorder that too infrequently presents in family practice to be diagnosed correctly. On the basis of these observations, RN Braun developed 82 diagnostic protocols for a structured recording of various complaints. METHOD All consultations during the years 2001 to 2014, in which 1 author (WF) had used diagnostic protocols in her single-handed practice, were analyzed retrospectively regarding reasons for encounter, diagnostic classification, and long-term outcome. RESULTS During the period, a diagnostic protocol was used 1686 times. It was applied at a rate of approximately 5% of 2500 new complaints annually, most often (1366 times) for febrile conditions. In 320 consultations for other complaints, 43 different diagnostic protocols were applied. Among them, the "tabula diagnostica" for various undifferentiated symptoms was used most frequently (n = 54), followed by diagnostic protocols for headache (n = 45), dizziness (n = 36), precordial pain (n = 20), nonspecific abdominal pain (n = 15), low back pain (n = 14), hypertension (n = 12), diarrhea > 1 week (n = 12), epigastralgia (n = 11), depression (n = 10), polyarthralgia (n = 8), cough, and lower abdominal pain (each n = 7). A final diagnosis was established in less than 20% of cases. CONCLUSIONS This observational study from routine practice gives an insight how diagnostic protocols helped to manage complex patient presentations. A broader use of diagnostic protocols could investigate the potential of this consultation tool to handle the complexity of primary health care. The use of a standardized diagnostic approach could stimulate research, in particular on managing common complaints/undifferentiated illness and their inherent diagnostic uncertainty.
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Affiliation(s)
- Waltraud Fink
- Straning, Austria.,Karl Landsteiner Institute for Systematics in General Medicine, Angern, Austria
| | - Gustav Kamenski
- Angern, Austria.,Department of General Practice, Center for Public Health, Medical University Vienna, Austria.,Karl Landsteiner Institute for Systematics in General Medicine, Angern, Austria
| | - Martin Konitzer
- Schwarmstedt, Germany.,Academic Teaching Practice Hannover Medical School (MHH), Hannover, Germany.,Karl Landsteiner Institute for Systematics in General Medicine, Angern, Austria
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Bujold M, Pluye P, Légaré F, Haggerty J, Gore GC, Sherif RE, Poitras MÈ, Beaulieu MC, Beaulieu MD, Bush PL, Couturier Y, Débarges B, Gagnon J, Giguère A, Grad R, Granikov V, Goulet S, Hudon C, Kremer B, Kröger E, Kudrina I, Lebouché B, Loignon C, Lussier MT, Martello C, Nguyen Q, Pratt R, Rihoux B, Rosenberg E, Samson I, Senn N, Li Tang D, Tsujimoto M, Vedel I, Ventelou B, Wensing M. Decisional needs assessment of patients with complex care needs in primary care: a participatory systematic mixed studies review protocol. BMJ Open 2017; 7:e016400. [PMID: 29133314 PMCID: PMC5695438 DOI: 10.1136/bmjopen-2017-016400] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Revised: 07/28/2017] [Accepted: 08/23/2017] [Indexed: 01/30/2023] Open
Abstract
INTRODUCTION Patients with complex care needs (PCCNs) often suffer from combinations of multiple chronic conditions, mental health problems, drug interactions and social vulnerability, which can lead to healthcare services overuse, underuse or misuse. Typically, PCCNs face interactional issues and unmet decisional needs regarding possible options in a cascade of interrelated decisions involving different stakeholders (themselves, their families, their caregivers, their healthcare practitioners). Gaps in knowledge, values clarification and social support in situations where options need to be deliberated hamper effective decision support interventions. This review aims to (1) assess decisional needs of PCCNs from the perspective of stakeholders, (2) build a taxonomy of these decisional needs and (3) prioritise decisional needs with knowledge users (clinicians, patients and managers). METHODS AND ANALYSIS This review will be based on the interprofessional shared decision making (IP-SDM) model and the Ottawa Decision Support Framework. Applying a participatory research approach, we will identify potentially relevant studies through a comprehensive literature search; select relevant ones using eligibility criteria inspired from our previous scoping review on PCCNs; appraise quality using the Mixed Methods Appraisal Tool; conduct a three-step synthesis (sequential exploratory mixed methods design) to build taxonomy of key decisional needs; and integrate these results with those of a parallel PCCNs' qualitative decisional need assessment (semistructured interviews and focus group with stakeholders). ETHICS AND DISSEMINATION This systematic review, together with the qualitative study (approved by the Centre Intégré Universitaire de Santé et Service Sociaux du Saguenay-Lac-Saint-Jean ethical committee), will produce a working taxonomy of key decisional needs (ontological contribution), to inform the subsequent user-centred design of a support tool for addressing PCCNs' decisional needs (practical contribution). We will adapt the IP-SDM model, normally dealing with a single decision, for PCCNs who experience cascade of decisions involving different stakeholders (theoretical contribution). Knowledge users will facilitate dissemination of the results in the Canadian primary care network. PROSPERO REGISTRATION NUMBER CRD42015020558.
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Affiliation(s)
- Mathieu Bujold
- Department of Family Medicine, McGill University, Montréal, Québec, Canada
| | - Pierre Pluye
- Department of Family Medicine, McGill University, Montréal, Québec, Canada
| | - France Légaré
- Department of Family Medicine and Emergency Medicine, Université Laval, Montréal, Québec, Canada
| | - Jeannie Haggerty
- Department of Family Medicine, McGill University, Montréal, Québec, Canada
| | | | - Reem El Sherif
- Department of Family Medicine, McGill University, Montréal, Québec, Canada
| | - Marie-Ève Poitras
- Department of Family Medicine and Emergency Medicine, Université Laval, Montréal, Québec, Canada
| | | | | | - Paula L Bush
- Department of Family Medicine, McGill University, Montréal, Québec, Canada
| | - Yves Couturier
- École de travail social, Université de Sherbrooke, Canada
| | | | - Justin Gagnon
- Department of Family Medicine, McGill University, Montréal, Québec, Canada
| | - Anik Giguère
- Department of Family Medicine and Emergency Medicine, Université Laval, Montréal, Québec, Canada
| | - Roland Grad
- Department of Family Medicine, McGill University, Montréal, Québec, Canada
| | - Vera Granikov
- Department of Family Medicine, McGill University, Montréal, Québec, Canada
| | - Serge Goulet
- Department of Family Medicine, Université de Sherbrooke, Canada
| | - Catherine Hudon
- Department of Family Medicine, Université de Sherbrooke, Canada
| | | | | | - Irina Kudrina
- Department of Family Medicine, McGill University, Montréal, Québec, Canada
| | - Bertrand Lebouché
- Department of Family Medicine, McGill University, Montréal, Québec, Canada
| | | | | | - Cristiano Martello
- Department of Family Medicine, McGill University, Montréal, Québec, Canada
| | - Quynh Nguyen
- Department of Family Medicine, McGill University, Montréal, Québec, Canada
| | - Rebekah Pratt
- Department of Family Medicine and Community Health, University of Minnesota, Minneapolis, United States
| | - Benoit Rihoux
- Centre de Science Politique et de Politique Comparée, Université catholique de Louvain, Belgium
| | - Ellen Rosenberg
- Department of Family Medicine, McGill University, Montréal, Québec, Canada
| | - Isabelle Samson
- Department of Family Medicine and Emergency Medicine, Université Laval, Montréal, Québec, Canada
| | | | - David Li Tang
- Department of Family Medicine, McGill University, Montréal, Québec, Canada
| | | | - Isabelle Vedel
- Department of Family Medicine, McGill University, Montréal, Québec, Canada
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Fontil V, Bibbins‐Domingo K, Nguyen OK, Guzman D, Goldman LE. Management of Hypertension in Primary Care Safety-Net Clinics in the United States: A Comparison of Community Health Centers and Private Physicians' Offices. Health Serv Res 2017; 52:807-825. [PMID: 27283354 PMCID: PMC5346492 DOI: 10.1111/1475-6773.12516] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVE To examine adherence to guideline-concordant hypertension treatment practices at community health centers (CHCs) compared with private physicians' offices. DATA SOURCES/STUDY SETTING National Ambulatory Medical Care Survey from 2006 to 2010. STUDY DESIGN We examined four guideline-concordant treatment practices: initiation of a new medication for uncontrolled hypertension, use of fixed-dose combination drugs for patients on multiple antihypertensive medications, use of thiazide diuretics among patients with uncontrolled hypertension on ≥3 antihypertensive medications, and use of aldosterone antagonist for resistant hypertension, comparing use at CHC with private physicians' offices overall and by payer group. DATA COLLECTION/EXTRACTION METHODS We identified visits of nonpregnant adults with hypertension at CHCs and private physicians' offices. PRINCIPAL FINDINGS Medicaid patients at CHCs were as likely as privately insured individuals to receive a new medication for uncontrolled hypertension (AOR 1.0, 95 percent CI: 0.6-1.9), whereas Medicaid patients at private physicians' offices were less likely to receive a new medication (AOR 0.3, 95 percent CI: 0.1-0.6). Use of fixed-dose combination drugs was lower at CHCs (AOR 0.6, 95 percent CI: 0.4-0.9). Thiazide use for patients was similar in both settings (AOR 0.8, 95 percent CI: 0.4-1.7). Use of aldosterone antagonists was too rare (2.1 percent at CHCs and 1.5 percent at private clinics) to allow for statistically reliable comparisons. CONCLUSIONS Increasing physician use of fixed-dose combination drugs may be particularly helpful in improving hypertension control at CHCs where there are higher rates of uncontrolled hypertension.
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Affiliation(s)
- Valy Fontil
- Division of General Internal MedicineSan Francisco General HospitalUniversity of California San FranciscoSan FranciscoCA
- UCSF Center for Vulnerable Populations at San Francisco General HospitalSan FranciscoCA
| | - Kirsten Bibbins‐Domingo
- Division of General Internal MedicineSan Francisco General HospitalUniversity of California San FranciscoSan FranciscoCA
- UCSF Center for Vulnerable Populations at San Francisco General HospitalSan FranciscoCA
- Department of Epidemiology and BiostatisticsUniversity of California San FranciscoSan FranciscoCA
| | - Oanh Kieu Nguyen
- Divisions of General Internal Medicine and Outcomes and Health Services ResearchUT SouthwesternDallasTX
| | - David Guzman
- Division of General Internal MedicineSan Francisco General HospitalUniversity of California San FranciscoSan FranciscoCA
| | - Lauren Elizabeth Goldman
- Division of General Internal MedicineSan Francisco General HospitalUniversity of California San FranciscoSan FranciscoCA
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Katerndahl D, Wood R, Jaen CR. Measuring interdependence in ambulatory care. J Eval Clin Pract 2017; 23:453-459. [PMID: 26663144 DOI: 10.1111/jep.12491] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/10/2015] [Indexed: 11/29/2022]
Abstract
RATIONALE, AIMS AND OBJECTIVES Complex systems differ from complicated systems in that they are nonlinear, unpredictable and lacking clear cause-and-effect relationships, largely due to the interdependence of their components (effects of interconnectedness on system behaviour and consequences). The purpose of this study was to demonstrate the potential for network density to serve as a measure of interdependence, assess its concurrent validity and test whether the use of valued or binary ties yields better results. METHOD This secondary analysis used the 2010 National Ambulatory Care Medical Survey to assess interdependence of 'top 20' diagnoses seen and medications prescribed for 14 specialties. The degree of interdependence was measured as the level of association between diagnoses and drug interactions among medications. Both valued and binary network densities were computed for each specialty. To assess concurrent validity, these measures were correlated with previously-derived valid measures of complexity of care using the same database, adjusting for diagnosis and medication diversity. RESULTS Partial correlations between diagnosis density, and both diagnosis and total input complexity, were significant, as were those between medication density and both medication and total output complexity; for both diagnosis and medication densities, adjusted correlations were higher for binary rather than valued densities. CONCLUSION This study demonstrated the feasibility and validity of using network density as a measure of interdependence. When adjusted for measure diversity, density-complexity correlations were significant and higher for binary than valued density. This approach complements other methods of estimating complexity of care and may be applicable to unique settings.
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Affiliation(s)
- David Katerndahl
- Family & Community Medicine, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Robert Wood
- Family & Community Medicine, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Carlos R Jaen
- Family & Community Medicine, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
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Young RA, Roberts RG, Holden RJ. The Challenges of Measuring, Improving, and Reporting Quality in Primary Care. Ann Fam Med 2017; 15:175-182. [PMID: 28289120 PMCID: PMC5348238 DOI: 10.1370/afm.2014] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2016] [Revised: 09/19/2006] [Accepted: 10/12/2016] [Indexed: 11/09/2022] Open
Abstract
We propose a new set of priorities for quality management in primary care, acknowledging that payers and regulators likely will continue to insist on reporting numerical quality metrics. Primary care practices have been described as complex adaptive systems. Traditional quality improvement processes applied to linear mechanical systems, such as isolated single-disease care, are inappropriate for nonlinear, complex adaptive systems, such as primary care, because of differences in care processes, outcome goals, and the validity of summative quality scorecards. Our priorities for primary care quality management include patient-centered reporting; quality goals not based on rigid targets; metrics that capture avoidance of excessive testing or treatment; attributes of primary care associated with better outcomes and lower costs; less emphasis on patient satisfaction scores; patient-centered outcomes, such as days of avoidable disability; and peer-led qualitative reviews of patterns of care, practice infrastructure, and intrapractice relationships.
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Affiliation(s)
- Richard A Young
- JPS Hospital Family Medicine Residency Program, Fort Worth, Texas
| | - Richard G Roberts
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Richard J Holden
- Indiana University School of Informatics and Computing, Bloomington, Indiana
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Roosan D, Weir C, Samore M, Jones M, Rahman M, Stoddard GJ, Del Fiol G. Identifying complexity in infectious diseases inpatient settings: An observation study. J Biomed Inform 2016; 71S:S13-S21. [PMID: 27818310 DOI: 10.1016/j.jbi.2016.10.018] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Revised: 10/02/2016] [Accepted: 10/31/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND Understanding complexity in healthcare has the potential to reduce decision and treatment uncertainty. Therefore, identifying both patient and task complexity may offer better task allocation and design recommendation for next-generation health information technology system design. OBJECTIVE To identify specific complexity-contributing factors in the infectious disease domain and the relationship with the complexity perceived by clinicians. METHOD We observed and audio recorded clinical rounds of three infectious disease teams. Thirty cases were observed for a period of four consecutive days. Transcripts were coded based on clinical complexity-contributing factors from the clinical complexity model. Ratings of complexity on day 1 for each case were collected. We then used statistical methods to identify complexity-contributing factors in relationship to perceived complexity of clinicians. RESULTS A factor analysis (principal component extraction with varimax rotation) of specific items revealed three factors (eigenvalues>2.0) explaining 47% of total variance, namely task interaction and goals (10 items, 26%, Cronbach's Alpha=0.87), urgency and acuity (6 items, 11%, Cronbach's Alpha=0.67), and psychosocial behavior (4 items, 10%, Cronbach's alpha=0.55). A linear regression analysis showed no statistically significant association between complexity perceived by the physicians and objective complexity, which was measured from coded transcripts by three clinicians (Multiple R-squared=0.13, p=0.61). There were no physician effects on the rating of perceived complexity. CONCLUSION Task complexity contributes significantly to overall complexity in the infectious diseases domain. The different complexity-contributing factors found in this study can guide health information technology system designers and researchers for intuitive design. Thus, decision support tools can help reduce the specific complexity-contributing factors. Future studies aimed at understanding clinical domain-specific complexity-contributing factors can ultimately improve task allocation and design for intuitive clinical reasoning.
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Affiliation(s)
- Don Roosan
- Department of Biomedical Informatics, University of Utah, 421 Wakara Way, Ste 140, Salt Lake City, UT 84018, USA; IDEAS Center of Innovation, VA Salt Lake City Health System, 500 Foothill Drive, Salt Lake City, UT 84148, USA; Health Services Research Section, Baylor College of Medicine, 2450 Holcombe Blvd, Houston, TX 77030, USA.
| | - Charlene Weir
- Department of Biomedical Informatics, University of Utah, 421 Wakara Way, Ste 140, Salt Lake City, UT 84018, USA; IDEAS Center of Innovation, VA Salt Lake City Health System, 500 Foothill Drive, Salt Lake City, UT 84148, USA.
| | - Matthew Samore
- IDEAS Center of Innovation, VA Salt Lake City Health System, 500 Foothill Drive, Salt Lake City, UT 84148, USA.
| | - Makoto Jones
- IDEAS Center of Innovation, VA Salt Lake City Health System, 500 Foothill Drive, Salt Lake City, UT 84148, USA.
| | - Mumtahena Rahman
- Department of Biomedical Informatics, University of Utah, 421 Wakara Way, Ste 140, Salt Lake City, UT 84018, USA.
| | - Gregory J Stoddard
- Department of Biomedical Informatics, University of Utah, 421 Wakara Way, Ste 140, Salt Lake City, UT 84018, USA; IDEAS Center of Innovation, VA Salt Lake City Health System, 500 Foothill Drive, Salt Lake City, UT 84148, USA.
| | - Guilherme Del Fiol
- Department of Biomedical Informatics, University of Utah, 421 Wakara Way, Ste 140, Salt Lake City, UT 84018, USA; IDEAS Center of Innovation, VA Salt Lake City Health System, 500 Foothill Drive, Salt Lake City, UT 84148, USA.
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Islam R, Weir CR, Jones M, Del Fiol G, Samore MH. Understanding complex clinical reasoning in infectious diseases for improving clinical decision support design. BMC Med Inform Decis Mak 2015; 15:101. [PMID: 26620881 PMCID: PMC4665869 DOI: 10.1186/s12911-015-0221-z] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2015] [Accepted: 11/24/2015] [Indexed: 11/10/2022] Open
Abstract
Background Clinical experts’ cognitive mechanisms for managing complexity have implications for the design of future innovative healthcare systems. The purpose of the study is to examine the constituents of decision complexity and explore the cognitive strategies clinicians use to control and adapt to their information environment. Methods We used Cognitive Task Analysis (CTA) methods to interview 10 Infectious Disease (ID) experts at the University of Utah and Salt Lake City Veterans Administration Medical Center. Participants were asked to recall a complex, critical and vivid antibiotic-prescribing incident using the Critical Decision Method (CDM), a type of Cognitive Task Analysis (CTA). Using the four iterations of the Critical Decision Method, questions were posed to fully explore the incident, focusing in depth on the clinical components underlying the complexity. Probes were included to assess cognitive and decision strategies used by participants. Results The following three themes emerged as the constituents of decision complexity experienced by the Infectious Diseases experts: 1) the overall clinical picture does not match the pattern, 2) a lack of comprehension of the situation and 3) dealing with social and emotional pressures such as fear and anxiety. All these factors contribute to decision complexity. These factors almost always occurred together, creating unexpected events and uncertainty in clinical reasoning. Five themes emerged in the analyses of how experts deal with the complexity. Expert clinicians frequently used 1) watchful waiting instead of over- prescribing antibiotics, engaged in 2) theory of mind to project and simulate other practitioners’ perspectives, reduced very complex cases into simple 3) heuristics, employed 4) anticipatory thinking to plan and re-plan events and consulted with peers to share knowledge, solicit opinions and 5) seek help on patient cases. Conclusion The cognitive strategies to deal with decision complexity found in this study have important implications for design future decision support systems for the management of complex patients. Electronic supplementary material The online version of this article (doi:10.1186/s12911-015-0221-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Roosan Islam
- Department of Biomedical Informatics, University of Utah, 421 Wakara Way, Ste 140, Salt Lake City, UT, 84108, USA. .,IDEAS Center for Innovation, VA Salt Lake City Health System, 500 Foothill Drive, Salt Lake City, UT, 84108, USA.
| | - Charlene R Weir
- Department of Biomedical Informatics, University of Utah, 421 Wakara Way, Ste 140, Salt Lake City, UT, 84108, USA.,IDEAS Center for Innovation, VA Salt Lake City Health System, 500 Foothill Drive, Salt Lake City, UT, 84108, USA
| | - Makoto Jones
- IDEAS Center for Innovation, VA Salt Lake City Health System, 500 Foothill Drive, Salt Lake City, UT, 84108, USA
| | - Guilherme Del Fiol
- Department of Biomedical Informatics, University of Utah, 421 Wakara Way, Ste 140, Salt Lake City, UT, 84108, USA.,IDEAS Center for Innovation, VA Salt Lake City Health System, 500 Foothill Drive, Salt Lake City, UT, 84108, USA
| | - Matthew H Samore
- Department of Biomedical Informatics, University of Utah, 421 Wakara Way, Ste 140, Salt Lake City, UT, 84108, USA.,IDEAS Center for Innovation, VA Salt Lake City Health System, 500 Foothill Drive, Salt Lake City, UT, 84108, USA
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Katerndahl D, Wood R, Jaén CR. Complexity of ambulatory care across disciplines. Healthcare (Basel) 2015; 3:89-96. [DOI: 10.1016/j.hjdsi.2015.02.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2014] [Revised: 01/15/2015] [Accepted: 02/03/2015] [Indexed: 11/17/2022] Open
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Roberts RG, Wynn-Jones J. Research and rural; EGPRN and EURIPA—finding common ground. October 2013, Malta. Eur J Gen Pract 2014; 21:77-81. [PMID: 25410820 DOI: 10.3109/13814788.2014.936006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
The European General Practice Research Network (EGPRN) and the European Rural and Isolated Practitioner Association (EURIPA) convened a historic joint meeting in Malta in October 2013. Speakers reviewed the inadequacies of the current system and conduct of clinical science research and the use and misuse of the resulting findings. Rural communities offer extraordinary opportunities to conduct more holistic, integrative, and relevant research using new methods and data sources. Investigators presented exciting research findings on questions important to the health of those in rural areas. Participants discussed several strategies to enhance the capacity and stature of rural health research and practice. EGPRN and EURIPA pledged to work together to develop rural research courses, joint research projects, and a European Rural Research Agenda based on the most urgent priorities and the European definition of general practice research in rural health care.
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Affiliation(s)
- Richard G Roberts
- University of Wisconsin School of Medicine & Public Health , Wisconsin , USA
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Miyata Y. [Series: For attending physicians; seeking to understand the diversity of medicine; what is community medicine?]. NIHON NAIKA GAKKAI ZASSHI. THE JOURNAL OF THE JAPANESE SOCIETY OF INTERNAL MEDICINE 2014; 103:466-74. [PMID: 24724388 DOI: 10.2169/naika.103.466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Sturmberg JP, Martin CM, Katerndahl DA. Systems and complexity thinking in the general practice literature: an integrative, historical narrative review. Ann Fam Med 2014; 12:66-74. [PMID: 24445105 PMCID: PMC3896540 DOI: 10.1370/afm.1593] [Citation(s) in RCA: 73] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
PURPOSE Over the past 7 decades, theories in the systems and complexity sciences have had a major influence on academic thinking and research. We assessed the impact of complexity science on general practice/family medicine. METHODS We performed a historical integrative review using the following systematic search strategy: medical subject heading [humans] combined in turn with the terms complex adaptive systems, nonlinear dynamics, systems biology, and systems theory, limited to general practice/family medicine and published before December 2010. A total of 16,242 articles were retrieved, of which 49 were published in general practice/family medicine journals. Hand searches and snowballing retrieved another 35. After a full-text review, we included 56 articles dealing specifically with systems sciences and general/family practice. RESULTS General practice/family medicine engaged with the emerging systems and complexity theories in 4 stages. Before 1995, articles tended to explore common phenomenologic general practice/family medicine experiences. Between 1995 and 2000, articles described the complex adaptive nature of this discipline. Those published between 2000 and 2005 focused on describing the system dynamics of medical practice. After 2005, articles increasingly applied the breadth of complex science theories to health care, health care reform, and the future of medicine. CONCLUSIONS This historical review describes the development of general practice/family medicine in relation to complex adaptive systems theories, and shows how systems sciences more accurately reflect the discipline's philosophy and identity. Analysis suggests that general practice/family medicine first embraced systems theories through conscious reorganization of its boundaries and scope, before applying empirical tools. Future research should concentrate on applying nonlinear dynamics and empirical modeling to patient care, and to organizing and developing local practices, engaging in community development, and influencing health care reform.
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Affiliation(s)
- Joachim P Sturmberg
- Department of General Practice, Newcastle University, Newcastle, New South Wales, Australia
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Katerndahl D, Parchman M. Effects of family presence on the content and dynamics of the clinical encounter among diabetic patients. J Eval Clin Pract 2013; 19:1067-72. [PMID: 23510440 DOI: 10.1111/jep.12028] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/30/2013] [Indexed: 11/28/2022]
Abstract
RATIONALE, AIMS AND OBJECTIVES Primary care visits often include a family member or friend. The purpose of this study was to determine the effect of the presence of a family member on the visit content and dynamics among diabetic patients in Family Medicine settings. METHOD Encounters of patients with type 2 diabetes from 20 primary care clinics were audio-recorded and transcribed. Encounters were coded using the Davis Observation Codes, classifying content into 20 different categories at 15-second intervals. A random sample of 30 patients with family members was selected; 30 encounters in which no family was present were then matched to the randomly selected patients so that they would be similar group-wise in A1C level, length of visit, level of distress and discussion of non-patient family problems for analysis using orbital decomposition, an analytic technique based on symbolic dynamics in which categorical time series data are used to identify amount of complexity present and recurrent patterns of strings. RESULTS Visits were more linear if family members were present. When family members were present, 90-second strings of preventive services and evaluation/feedback were observed while 90 seconds of exercise discussion occurred when they were absent. Visits without family members tended to include more chatting, compliance discussion and nutrition counselling, while those with family members included more patient questions and evaluation/feedback. Finally, the sequence of history-to-planning-to-evaluation was observed when family were absent, but evaluation-to-planning-to-history when family were present. CONCLUSION The presence of a family member was associated with increased linearity and recurrent patterns that focused more on evaluation/feedback, preventive services, and patient questions, and less on chatting, exercise, compliance and nutrition in diabetic encounters.
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Affiliation(s)
- David Katerndahl
- University of Texas Health Science Center, San Antonio, Texas, USA
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Roberts RG. The art of family doctoring: A global view. Eur J Gen Pract 2013; 19:59-61. [DOI: 10.3109/13814788.2012.760197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Bjerre LM, Paterson NR, McGowan J, Hogg W, Campbell CM, Viner G, Archibald D. What do primary care practitioners want to know? A content analysis of questions asked at the point of care. THE JOURNAL OF CONTINUING EDUCATION IN THE HEALTH PROFESSIONS 2013; 33:224-234. [PMID: 24347101 DOI: 10.1002/chp.21191] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
INTRODUCTION Assessing physician needs to develop continuing medical education (CME) activities is an integral part of CME curriculum development. The purpose of the present study was to demonstrate the feasibility of identifying areas of perceived greatest needs for continuing medical education (CME) by using questions collected electronically at the point of care. METHODS This study is a secondary analysis of the "Just-in-Time" (JIT) information librarian consultation service database of questions using quantitative content analysis methods. The original JIT project demonstrated the feasibility of a real-time librarian service for answering questions asked by primary care clinicians at the point of care using a Web-based platform or handheld device. Data were collected from 88 primary care practitioners in Ontario, Canada, from October 2005 to April 2006. Questions were answered in less than 15 minutes, enabling clinicians to use the answer during patient encounters. RESULTS Description of type and frequency of questions asked, including the organ system on which the questions focused, was produced using 2 classification systems, the "taxonomy of generic clinical questions" (TGCQ), and the International Classification for Primary Care version 2 (ICPC-2). Of the original 1889 questions, 1871 (99.0%) were suitable for analysis. A total of 970 (52%) of questions related to therapy; of these, 671 (69.2%) addressed questions about drug therapy, representing 36% of all questions. Questions related to diagnosis (24.8%) and epidemiology (13.5%) were also common. Organ systems questions concerning musculoskeletal, endocrine, skin, cardiac, and digestive systems were asked more than other categories. DISCUSSION Questions collected at the point of care provide a valuable and unique source of information on the true learning needs of practicing clinicians. The TGCQ classification allowed us to show that a majority of questions had to do with treatment, particularly drug treatment, whereas the use of the ICPC-2 classification illustrated the great variety of questions asked about the diverse conditions encountered in primary care. It is feasible to use electronically collected questions asked by primary care clinicians in clinical practice to categorize self-identified knowledge and practice needs. This could be used to inform the development of future learning activities.
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Affiliation(s)
- Lise M Bjerre
- Department of Family Medicine, University of Ottawa, Ottawa, Canada;; C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, Canada;; Department of Epidemiology and Community Medicine, University of Ottawa, Canada;.
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Katz A, Halas G, Dillon M, Sloshower J. Describing the content of primary care: limitations of Canadian billing data. BMC FAMILY PRACTICE 2012; 13:7. [PMID: 22335900 PMCID: PMC3305652 DOI: 10.1186/1471-2296-13-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/25/2011] [Accepted: 02/15/2012] [Indexed: 11/10/2022]
Abstract
Background Primary health care systems are designed to provide comprehensive patient care. However, the ICD 9 coding system used for billing purposes in Canada neither characterizes nor captures the scope of clinical practice or complexity of physician-patient interactions. This study aims to describe the content of primary care clinical encounters and examine the limitations of using administrative data to capture the content of these visits. Although a number of U.S studies have described the content of primary care encounters, this is the first Canadian study to do so. Methods Study-specific data collection forms were completed by 16 primary care physicians in community health and family practice clinics in Winnipeg, Manitoba, Canada. The data collection forms were completed immediately following the patient encounter and included patient and visit characteristics, such as primary reason for visit, topics discussed, actions taken, degree of complexity as well as diagnosis and ICD-9 codes. Results Data was collected for 760 patient encounters. The diagnostic codes often did not reflect the dominant topic of the visit or the topic requiring the most amount of time. Physicians often address multiple problems and provide numerous services thus increasing the complexity of care. Conclusion This is one of the first Canadian studies to critically analyze the content of primary care clinical encounters. The data allowed a greater understanding of primary care clinical encounters and attests to the deficiencies of singular ICD-9 coding which fails to capture the comprehensiveness and complexity of the primary care encounter. As primary care reform initiatives in the U.S and Canada attempt to transform the way family physicians deliver care, it becomes increasingly important that other tools for structuring primary care data are considered in order to help physicians, researchers and policy makers understand the breadth and complexity of primary care.
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Affiliation(s)
- Alan Katz
- Department of Family Medicine, Faculty of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada.
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Fiscella K. Health care reform and equity: promise, pitfalls, and prescriptions. Ann Fam Med 2011; 9:78-84. [PMID: 21242565 PMCID: PMC3022050 DOI: 10.1370/afm.1213] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2010] [Revised: 10/18/2010] [Accepted: 11/07/2010] [Indexed: 11/09/2022] Open
Abstract
The United States has made little progress during the past decade in addressing health care disparities. Recent health care reforms offer an historic opportunity to create a more equitable health care system. Key elements of health care reform relevant to promoting equity include access, support for primary care, enhanced health information technology, new payment models, a national quality strategy informed by research, and federal requirements for health care disparity monitoring. With effective implementation, improved alignment of resources with patient needs, and most importantly, revitalization of primary care, these reforms could measurably improve equity.
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Affiliation(s)
- Kevin Fiscella
- Department of Family Medicine and Community & Preventive Medicine, University of Rochester, Rochester, NY, USA.
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Abstract
Making sense of complex adaptive clinical practice and health systems is a pressing challenge as health services continue to struggle to adapt to changing internal and external constraints. In this Forum, we begin with Dervin's Sense-Making theories and research in communications. This provides a conceptual and theoretical context for this editions research on comparative complexity of family medicine consultations in the USA, models for adaptive leadership in clinical care and social networking to make sense of health promotion challenges for young people. Finally, a Sense-Making schema is proposed.
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Stange KC. Ethics, support for care, prevention, and what's important. Ann Fam Med 2010; 8:290-1. [PMID: 20644181 PMCID: PMC2906521 DOI: 10.1370/afm.1149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
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