National Trends in Primary Care Visit Use and Practice Capabilities, 2008-2015

Saxon Epidemiological Study in General Practice-6 (SESAM-6): protocol of a cross-sectional study

INTRODUCTION

General practitioners (GPs) are mostly the first point of contact for patients with health problems in Germany. There is only a limited epidemiological overview data that describe the GP consultation hours based on other than billing data. Therefore, the aim of Saxon Epidemiological Study in General Practice-6 (SESAM-6) is to examine the frequency of reasons for encounter, prevalence of long-term diagnosed diseases and diagnostic and therapeutic decisions in general practice. This knowledge is fundamental to identify the healthcare needs and to develop strategies to improve the GP care. The results of the study will be incorporated into the undergraduate, postgraduate and continuing medical education for GP.

METHODS AND ANALYSIS

This cross-sectional study SESAM-6 is conducted in general practices in the state of Saxony, Germany. The study design is based on previous SESAM studies. Participating physicians are assigned to 1 week per quarter (over a survey period of 12 months) in which every fifth doctor-patient contact is recorded for one-half of the day (morning or afternoon). To facilitate valid statements, a minimum of 50 GP is required to document a total of at least 2500 doctor-patient contacts. Univariable, multivariable and subgroup analyses as well as comparisons to the previous SESAM data sets will be conducted.

ETHICS AND DISSEMINATION

The study was approved by the Ethics Committee of the Technical University of Dresden in March 2023 (SR-EK-7502023). Participation in the study is voluntary and will not be remunerated. The study results will be published in peer-reviewed scientific journals, preferably with open access. They will also be disseminated at scientific and public symposia, congresses and conferences. A final report will be published to summarise the central results and provided to all study participants and the public.

Increasing Postpartum Primary Care Engagement through Default Scheduling and Tailored Messaging: A Randomized Clinical Trial

Importance

Over 30% of pregnant people have at least one chronic medical condition, and nearly 20% develop gestational diabetes or pregnancy-related hypertension, increasing the risk of future chronic disease. While these individuals are often monitored closely during pregnancy, they face significant barriers when transitioning to primary care following delivery, due in part to a lack of health care support for this transition.

Objective

To evaluate the impact of an intervention designed to improve postpartum primary care engagement by reducing patient administrative burden and information gaps.

Design

Individual-level randomized controlled trial conducted from November 3, 2022 to October 11, 2023.

Setting

One hospital-based and five community-based outpatient obstetric clinics affiliated with a large academic medical center.

Participants

Participants included English- and Spanish-speaking pregnant or recently postpartum adults with obesity, anxiety, depression, diabetes mellitus, chronic hypertension, gestational diabetes, or pregnancy-related hypertension, and a primary care practitioner (PCP) listed in their electronic health record (EHR).

Intervention

A behavioral economics-informed intervention bundle, including default scheduling of postpartum PCP appointments and tailored messages.

Main Outcome

Completion of a PCP visit for routine or chronic condition care within 4 months of delivery.

Results

360 patients were randomized (Control: N=176, Intervention: N=184). Individuals had mean (SD) age 34.1 (4.9) years and median gestational age of 36.3 weeks (interquartile range (IQR) 34.0-38.6 weeks) at enrollment. The distribution of self-reported races was 7.4% Asian, 6.8% Black, 15.0% multiple races or "Other," and 68.6% White. Most (75.8%) participants had anxiety or depression, 15.9% had a chronic or pregnancy-related hypertensive disorder, 19.8% had pre-existing or gestational diabetes, and 40.4% had a pre-pregnancy BMI ≥30 kg/m2. Medicaid was the primary payer for 21.9% of patients. PCP visit completion within 4 months occurred in 22.0% in the control group and 40.0% in the intervention group. In regression models accounting for randomization strata, the intervention increased PCP visit completion by 18.7 percentage points (95%CI 10.7-29.1). Intervention participants also had fewer postpartum readmissions (1.7 vs. 5.8%) and increased receipt of the following services by a PCP: blood pressure screening (42.8 vs. 28.3%), weight assessment (42.8 vs. 27.7%), and depression screening (32.8 vs. 16.8%).

Conclusions and Relevance

In this randomized trial of pregnant individuals with or at risk for chronic health conditions, default PCP visit scheduling, tailored messages, and reminders substantially improved postpartum primary care engagement. The current lack of support for postpartum transitions to primary care is a missed opportunity to improve recently pregnant individual's short- and long-term health. Reducing patient administrative burdens may represent relatively low-resource, high-impact approaches to improving postpartum health and wellbeing.

Trial Registration

NCT05543265.

Piloting a brief assessment to capture consumption of whole plant food and water: version 1.0 of the American College of Lifestyle Medicine Diet Screener (ACLM Diet Screener)

Background

Despite the availability of various dietary assessment tools, there is a need for a tool aligned with the needs of lifestyle medicine (LM) physicians. Such a tool would be brief, aimed at use in a clinical setting, and focused on a "food as medicine" approach consistent with recommendations for a diet based predominately on whole plant foods. The objective of this study is to describe the development and initial pilot testing of a brief, dietary screener to assess the proportion of whole, unrefined plant foods and water relative to total food and beverage intake.

Methods

A multidisciplinary study team led the screener development, providing input on the design and food/beverage items included, and existing published dietary assessment tools were reviewed for relevance. Feedback was solicited from LM practitioners in the form of a cross-sectional survey that captured information on medical practice, barriers, and needs in assessing patients' diets, in addition to an opportunity to complete the screener and provide feedback on its utility. The study team assessed feedback and revised the screener accordingly, which included seeking and incorporating feedback on additional food items to be included from subject matter experts in specific cultural and ethnic groups in the United States. The final screener was submitted for professional design, and scoring was developed.

Results

Of 539 total participants, the majority reported assessing diet either informally (62%) or formally (26%) during patient encounters, and 73% reported discussing diet with all or most of their patients. Participants also reported facing barriers (80%) to assessing diet. Eighty-eight percent believed the screener was quick enough to use in a clinical setting, and 68% reported they would use it.

Conclusion

The ACLM Diet Screener was developed through iterative review and pilot testing. The screener is a brief, 27-item diet assessment tool that can be successfully used in clinical settings to track patient dietary intakes, guide clinical conversations, and support nutrition prescriptions. Pilot testing of the screener found strong alignment with clinician needs for assessing a patient's intake of whole plant food and water relative to the overall diet. Future research will involve pilot testing the screener in clinical interventions and conducting a validation study to establish construct validity.

Patients' Perspectives on Plans Generated During Primary Care Visits and Self-Reported Adherence at 3 Months: Data From a Randomized Trial

BACKGROUND

Effective primary care necessitates follow-up actions by the patient beyond the visit. Prior research suggests room for improvement in patient adherence.

OBJECTIVE

This study sought to understand patients' views on their primary care visits, the plans generated therein, and their self-reported adherence after 3 months.

METHODS

As part of a large multisite cluster randomized pragmatic trial in 3 health care organizations, patients completed 2 surveys-the first within 7 days after the index primary care visit and another 3 months later. For this analysis of secondary outcomes, we combined the results across all study participants to understand patient adherence to care plans. We recorded patient characteristics and survey responses. Cross-tabulation and chi-square statistics were used to examine bivariate associations, adjusting for multiple comparisons when appropriate. We used multivariable logistic regression to assess how patients' intention to follow, agreement, and understanding of their plans impacted their plan adherence, allowing for differences in individual characteristics. Qualitative content analysis was conducted to characterize the patient's self-reported plans and reasons for adhering (or not) to the plan 3 months later.

RESULTS

Of 2555 patients, most selected the top box option (9=definitely agree) that they felt they had a clear plan (n=2011, 78%), agreed with the plan (n=2049, 80%), and intended to follow the plan (n=2108, 83%) discussed with their provider at the primary care visit. The most common elements of the plans reported included reference to exercise (n=359, 14.1%), testing (laboratory, imaging, etc; n=328, 12.8%), diet (n=296, 11.6%), and initiation or adjustment of medications; (n=284, 11.1%). Patients who strongly agreed that they had a clear plan, agreed with the plan, and intended to follow the plan were all more likely to report plan completion 3 months later (P<.001) than those providing less positive ratings. Patients who reported plans related to following up with the primary care provider (P=.008) to initiate or adjust medications (P≤.001) and to have a specialist visit were more likely to report that they had completely followed the plan (P=.003). Adjusting for demographic variables, patients who indicated intent to follow their plan were more likely to follow-through 3 months later (P<.001). Patients' reasons for completely following the plan were mainly that the plan was clear (n=1114, 69.5%), consistent with what mattered (n=1060, 66.1%), and they were determined to carry through with the plan (n=887, 53.3%). The most common reasons for not following the plan were lack of time (n=217, 22.8%), having decided to try a different approach (n=105, 11%), and the COVID-19 pandemic impacted the plan (n=105, 11%).

CONCLUSIONS

Patients' initial assessment of their plan as clear, their agreement with the plan, and their initial willingness to follow the plan were all strongly related to their self-reported completion of the plan 3 months later. Patients whose plans involved lifestyle changes were less likely to report that they had "completely" followed their plan.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03385512; https://clinicaltrials.gov/study/NCT03385512.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/30431.

Effects of extending residencies on the supply and quality of family medicine practitioners; difference-in-differences evidence from the implementation of mandatory family medicine residencies in Canada

I examine the impacts of extending residency training programs on the supply and quality of physicians practicing primary care. I leverage mandated extended residency lengths for primary care practitioners that were rolled out over 20 years in Canada on a province-by-province basis. I compare these primary care specialties to other specialties that did not change residency length (first difference) before and after the policy implementation (second difference) to assess how physician supply evolved in response. To examine quality outcomes, I use a set of scraped data and repeat this difference-in-differences identification strategy for complaints resulting in censure against physicians in Ontario. I find declines in the number of primary care providers by 5% for up to 9 years after the policy change. These changes are particularly pronounced in new graduates and younger physicians, suggesting that the policy change dissuaded these physicians from entering primary care residencies. I find no impacts on quality of physicians as measured by public censure of physicians. This suggests that extending primary care training caused declines in physician supply without improvement in the quality of these physicians. This has implications for current plans to extend residency training programs.

Hypertension Prevalence and Control Among U.S. Women of Reproductive Age

INTRODUCTION

Hypertension is a risk factor for cardiovascular disease, a leading cause of death among women of reproductive age (women aged 18-44 years). This study estimated hypertension prevalence and control among women of reproductive age at the national and state levels using electronic health record data.

METHODS

Nonpregnant women of reproductive age were included in this cross-sectional study using 2019 IQVIA Ambulatory Electronic Medical Records - U.S. national data (analyzed in 2023). Suspected hypertension was identified using any of these criteria: ≥1 hypertension diagnosis code, ≥2 blood pressure readings ≥140/90 mmHg on separate days, or ≥1 antihypertensive medication. Among women of reproductive age with hypertension, the latest blood pressure in 2019 was used to identify hypertension control (blood pressure <140/90 mmHg). Estimates were age standardized and stratified by race or Hispanic ethnicity, region, and states with sufficient data. Tukey tests compared estimates by race or Hispanic ethnicity, region, and comorbidities.

RESULTS

Among 2,125,084 women of reproductive age (62.1% White, 8.8% Black, and 29.1% other [including Hispanic, Asian, other, or unknown]) with a mean age of 31.7 years, hypertension prevalence was 14.5%. Of those with hypertension, 71.9% had controlled blood pressure. Black women of reproductive age had a higher hypertension prevalence (22.3% vs 14.4%, p<0.05) but lower control (60.6% vs 74.0%, p<0.05) than White women of reproductive age. State-level hypertension prevalence ranged from 13.7% (Massachusetts) to 36% (Alabama), and control ranged from 82.9% (Kansas) to 59.2% (the District of Columbia).

CONCLUSIONS

This study provides the first state-level estimates of hypertension control among women of reproductive age. Electronic health record data complements traditional hypertension surveillance data and provides further information for efforts to prevent and manage hypertension among women of reproductive age.

Designing Worthy Waiting Spaces: A Cross-Cultural Study of Waiting Room Features and Their Impact on Women's Affective States

OBJECTIVE

This study examines the impact of ambulatory waiting room characteristics on patients' emotional states and investigates whether these states are universally experienced or influenced by social and cultural factors among women aged 18-35 from the three largest demographic groups in the United States: Black, Hispanic/Latina, and White.

BACKGROUND

Patients typically spend more time waiting for routine medical appointments than receiving care, and evidence suggests that waiting can reinforces power dynamics that benefit privileged groups, leading to different experiences for minority women seeking preventative care. Still, literature addressing the impact of waiting areas is largely limited to universal measures, and little is known about how different ethnic/race groups respond to waiting spaces.

METHODS

This inquiry used a questionnaire assessing 15 waiting room characteristics and testing four variables (furniture arrangement, room-scale, color saturation, and quantity of positive distractions) in a 2 × 3 quasiexperiment using a fractional randomized block design with 24 waiting room images.

FINDINGS

Responses from 1,114 participants revealed mutual preferences for sociopetal seating, positive distractions, neutral colors, and welcoming and calming environments. Yet, Black participants indicated significantly greater importance in seeing ethnically/racially similar patients and healthcare providers and strategies that promote transparency, including image-based provider directories and views into the clinic.

CONCLUSION

By investigating the impact of the waiting room environment on patient affect and comparing perceptions across three demographic groups of women, this study offers insights into potential strategies for improving access to preventative care services by creating more welcoming ambulatory care waiting environments.

Characteristics of patients attached to near-retirement family physicians: a population-based serial cross-sectional study in Ontario, Canada

OBJECTIVES

Population ageing is a global phenomenon. Resultant healthcare workforce shortages are anticipated. To ensure access to comprehensive primary care, which correlates with improved health outcomes, equity and costs, data to inform workforce planning are urgently needed. We examined the medical and social characteristics of patients attached to near-retirement comprehensive primary care physicians over time and explored the early-career and mid-career workforce's capacity to absorb these patients.

DESIGN

A serial cross-sectional population-based analysis using health administrative data.

SETTING

Ontario, Canada, where most comprehensive primary care is delivered by family physicians (FPs) under universal insurance.

PARTICIPANTS

All insured Ontario residents at three time points: 2008 (12 936 360), 2013 (13 447 365) and 2019 (14 388 566) and all Ontario physicians who billed primary care services (2008: 11 566; 2013: 12 693; 2019: 15 054).

OUTCOME MEASURES

The number, proportion and health and social characteristics of patients attached to near-retirement age comprehensive FPs over time; the number, proportion and characteristics of near-retirement age comprehensive FPs over time.

SECONDARY OUTCOME MEASURES

The characteristics of patients and their early-career and mid-career comprehensive FPs.

RESULTS

Patient attachment to comprehensive FPs increased over time. The overall FP workforce grew, but the proportion practicing comprehensiveness declined (2008: 77.2%, 2019: 70.7%). Over time, an increasing proportion of the comprehensive FP workforce was near retirement age. Correspondingly, an increasing proportion of patients were attached to near-retirement physicians. By 2019, 13.9% of comprehensive FPs were 65 years or older, corresponding to 1 695 126 (14.8%) patients. Mean patient age increased, and all physicians served markedly increasing numbers of medically and socially complex patients.

CONCLUSIONS

The primary care sector faces capacity challenges as both patients and physicians age and fewer physicians practice comprehensiveness. Nearly 15% (1.7 million) of Ontarians may lose their comprehensive FP to retirement between 2019 and 2025. To serve a growing, increasingly complex population, innovative solutions are needed.

Proportion Of Preventive Primary Care Visits Nearly Doubled, Especially Among Medicare Beneficiaries, 2001-19

There is debate about the value of preventive visits in primary care, and multiple policy trends during the past fifteen years may have influenced the likelihood of US adults undergoing preventive primary care visits. Using nationally representative, serial cross-sectional data on adult visits to primary care physicians from the 2001-19 National Ambulatory Medical Care Survey, we characterized temporal trends in the proportion of primary care visits with a preventive focus and the differential characteristics of these visits. Based on a sample of 139,783 unweighted (5,902,144,258 weighted) US primary care visits, we found that the proportion of primary care visits with a preventive focus increased between 2001 and 2019 (12.8 percent of visits in 2001-02 versus 24.6 percent in 2018-19; [Formula: see text]), with the greatest rate of increase seen for people with Medicare. Primary care visits with a preventive focus involved more time spent with the physician and addressed fewer reasons for the visit compared with problem-based visits. At least one of the following was significantly more likely to occur during a preventive visit than a problem-based visit: counseling provision, ordering of preventive labs, or ordering of a preventive image or procedure. Our findings demonstrate a relative increase in preventive versus problem-based visits in primary care and suggest the importance of enhanced insurance coverage in influencing preventive care delivery trends.

Trends in Prescribing of Non-steroidal Anti-inflammatory Medications in the US Ambulatory Care Setting From 2006 to 2016

While opioid prescribing has significantly decreased from a peak in 2012, less is known about the national utilization of non-opioid analgesics such as non-steroidal anti-inflammatory drugs (NSAIDs) and acetaminophen (APAP) in the context of the opioid crisis. The objective of this study is to characterize the prescribing trends of NSAIDs and APAP in the US ambulatory care setting. We conducted repeated cross-sectional analyses using the 2006-2016 National Ambulatory Medical Care Survey. NSAID-involved visits were defined as patient visits among adults in which NSAIDs were ordered, supplied, administered, or continued. We used similarly-defined APAP visits as a referent group for context. After excluding aspirin and other NSAID/APAP combination products containing opioids, we calculated the annual proportion of NSAID-involved visits among all ambulatory visits. We conducted trend analyses using multivariable logistic regression adjusted for years, patient, and prescriber characteristics. From 2006 to 2016, there were 775.7 million NSAID-involved visits and 204.3 million APAP-involved visits. Most NSAIDs-involved visits were from patients aged 46-64 years (39.6%), female (60.4%), White (83.2%), and having commercial insurance (49.0%). There were significant increasing trends for the proportion of NSAID-involved visits (8.1-9.6%) and APAP-involved visits (1.7-2.9%) (both P < .0001). We observed an overall increase in NSAID and APAP-involved visits in US ambulatory care settings from 2006 to 2016. This trend may be attributed to decreasing opioid prescribing and raises safety concerns related to acute or chronic NSAID and APAP use. PERSPECTIVE: This study shows an overall increasing trend in NSAID use reported in nationally representative ambulatory care visits in the United States. This increase coincides with previously reported significant decreases in opioid analgesic use, particularly after 2012. Given the safety concerns related to chronic or acute NSAID use, there is a need to continue monitoring the use trends of this class of medication.

A window of opportunity: Adverse childhood experiences and time alone with a provider in the United States

BACKGROUND

To date, there is limited literature on the relationship between Adverse Childhood Experiences (ACEs) and the quality of health care provider encounters. This is key, as people with a history of ACEs have a greater burden of illness.

METHODS

This study uses data from the 2020-2021 National Survey of Children's Health to examine relationships between ACEs and (1) spending less than ten minutes with a health care provider, and (2) spending time alone with a health care provider.

RESULTS

In general, our results suggested most ACEs were associated with higher odds of a provider spending <10 min with a child during their last preventative care visit, while ACEs were inconsistently related to spending time alone with a provider. Each additional ACE was found to be associated with higher odds of both outcomes.

CONCLUSIONS

This work emphasizes the importance of ACEs screening in a health care setting and may set the groundwork for future research investigating mechanisms within these associations. Given the established link between health care quality and patient-provider trust, and health outcomes, intervention work is needed to develop healthcare practices that may encourage the length and quality of health care provider visits.

Defining and identifying laboratory literacy as a component of health literacy: An assessment of existing health literacy tools

Health literacy has been defined and studied as an important component of a patient's ability to understand and obtain appropriate healthcare. However, a laboratory component of health literacy, as it pertains to the understanding of laboratory tests and their results, has not been previously defined. An analysis of readily available health literacy tools was conducted to determine laboratory testing-specific content representation. One hundred and four health literacy tools from a publicly available database were analyzed. Many of the health literacy tools were found to be lacking items related to laboratory testing. Of the health literacy tools that did contain a laboratory component, they were categorized pertaining to the laboratory test/testing content. Emerging from this process, eight competencies were identified that encompassed the entire range of laboratory-related aspects of health literacy. We propose that these eight competencies form the basis of a set of competencies needed for one to access, interpret, and act on laboratory results-a capacity we are referring to as "laboratory literacy."

One Pandemic, Two Solutions: Comparing the U.S.-China Response and Health Priorities to COVID-19 from the Perspective of "Two Types of Control"

After three years of global rampage, the COVID-19 epidemic, the most serious infectious disease to occur worldwide since the 1918 influenza pandemic, is nearing its end. From the global experience, medical control and social control are the two main dimensions in the prevention and control of COVID-19. From the perspective of "two types of control", namely medical control and social control, this paper finds that the political system, economic structure, and cultural values of the United States greatly limit the government's ability to impose social control, forcing it to adopt medical control to fight the virus in a single dimension. In contrast, China's political system, economic structure, and cultural values allow its government to adopt stringent, extensive, and frequent social control, as well as medical control to fight the virus. This approach departs from the traditional pathway of fighting the epidemic, i.e., "infection-treatment-immunization", thereby outpacing the evolution of the virus and controlling its spread more rapidly. This finding helps explain why the Chinese government adopted a strict "zeroing" and "dynamic zeroing" policy during the first three years, at the cost of enormous economic, social, and even political legitimacy. It was not until late 2022, when the Omicron variant with the waning virulence became prevalent, that China chose to "coexist" with the virus, thus avoiding a massive epidemic-related death. While the United States adopted a pulsed-style strategy at the beginning of the epidemic, i.e., "relaxation-suppression-relaxation-suppression", and began to "coexist" with the virus in just one year, resulting in a large number of excess deaths associated with the epidemic. The study contributes to explaining the difference in the interplay between public health priorities and COVID-19 response strategies in China and the United States, based on the specific public health context and the perspective of "medical control" and "social control".

Race, Ethnicity, and Socioeconomic Factors as Determinants of Cachexia Incidence and Outcomes in a Retrospective Cohort of Patients With Gastrointestinal Tract Cancer

PURPOSE

Cachexia is a paraneoplastic syndrome of unintentional adipose and muscle tissue wasting with severe impacts to functionality and quality of life. Although health inequities across minority and socioeconomically disadvantaged groups are known, the role of these factors in cachexia progression is poorly characterized. This study aims to evaluate the relationship between these determinants and cachexia incidence and survival in patients with gastrointestinal tract cancer.

METHODS

Through retrospective chart review from a prospective tumor registry, we established a cohort of 882 patients with gastroesophageal or colorectal cancer diagnosed between 2006 and 2013. Patient race, ethnicity, private insurance coverage, and baseline characteristics were evaluated through multivariate, Kaplan-Meier, and Cox regression analyses to determine associations with cachexia incidence and survival outcomes.

RESULTS

When controlling for potentially confounding covariates (age, sex, alcohol and tobacco history, comorbidity score, tumor site, histology, and stage), Black (odds ratio [OR], 2.447; P < .0001) and Hispanic (OR, 3.039; P < .0001) patients are at an approximately 150% and 200%, respectively, greater risk of presenting with cachexia than non-Hispanic White patients. Absence of private insurance coverage was associated with elevated cachexia risk (OR, 1.439; P = .0427) compared to privately insured patients. Cox regression analyses with previously described covariates and treatment factors found Black race (hazard ratio [HR], 1.304; P = .0354) to predict survival detriments, while cachexia status did not reach significance (P = .6996).

CONCLUSION

Our findings suggest that race, ethnicity, and insurance play significant roles in cachexia progression and related outcomes that are not accounted for by conventional predictors of health. Disproportionate financial burdens, chronic stress, and limitations of transportation and health literacy represent targetable factors for mitigating these health inequities.

Patient Cost Exposure And Use Of Preventive Care Among ACA-Compliant Individual Plans

The Affordable Care Act (ACA) mandated coverage of common preventive services with zero patient cost sharing. However, patients may still experience high same-day costs when receiving these "zero-dollar" preventive services. Our analysis of on- and off-exchange individual-market health plans during 2016-18 revealed that 21-61 percent of enrollees experienced same-day cost exposure greater than $0 when accessing ACA-mandated free preventive services.

Association of Primary Care Visit Length With Potentially Inappropriate Prescribing

Importance

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

Objective

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

Design, Setting, and Participants

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

Main Outcomes and Measures

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

Results

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

Conclusions and Relevance

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

Trends and Disparities in the Distribution of Outpatient Physicians' Annual Face Time with Patients, 1979-2018

BACKGROUND

Physician time is a valuable yet finite resource. Whether such time is apportioned equitably among population subgroups, and how the provision of that time has changed in recent decades, is unclear.

OBJECTIVE

To investigate trends and racial/ethnic disparities in the receipt of annual face time with physicians in the USA.

DESIGN

Repeated cross-sectional.

SETTING

National Ambulatory Medical Care Survey, 1979-1981, 1985, 1989-2016, 2018.

PARTICIPANTS

Office-based physicians.

MEASURES

Exposures included race/ethnicity (White, Black, and Hispanic); age (<18, 18-64, and 65+); and survey year. Our main outcome was patients' annual visit face time with a physician; secondary outcomes include annual visit rates and mean visit duration.

RESULTS

Our sample included n=1,108,835 patient visits. From 1979 to 2018, annual outpatient physician face time per capita rose from 40.0 to 60.4 min, an increase driven by a rise in mean visit length and not in the number of visits. However, since 2005, mean annual face time with a primary care physician has fallen, a decline offset by rising time with specialists. Face time provided per physician changed little given growth in the physician workforce. A racial/ethnic gap in physician visit time present at the beginning of the study period widened over time. In 2014-2018, White individuals received 70.0 min of physician face time per year, vs. 52.4 among Black and 53.0 among Hispanic individuals. This disparity was driven by differences in visit rates, not mean visit length, and in the provision of specialist but not primary care.

LIMITATION

Self-reported visit length.

CONCLUSION

Americans' annual face time with office-based physicians rose for three decades after 1979, yet is still allocated inequitably, particularly by specialists; meanwhile, time spent by Americans with primary care physicians is falling. These trends and disparities may adversely affect patient outcomes. Policy change is needed to assure better allocation of this resource.

The Registrar Clinical Encounters in Training (ReCEnT) cohort study: updated protocol

BACKGROUND

During vocational general practice training, the content of each trainee's (in Australia, registrars') in-consultation clinical experience is expected to entail a breadth of conditions that exemplify general practice, enabling registrars to gain competency in managing common clinical conditions and common clinical scenarios. Prior to the Registrar Clinical Encounters in Training (ReCEnT) project there was little research into the content of registrars' consultations despite its importance to quality of training. ReCEnT aims to document the consultation-based clinical and educational experiences of individual Australian registrars.

METHODS

ReCEnT is an inception cohort study. It is comprised of closely interrelated research and educational components. Registrars are recruited by participating general practice regional training organisations. They provide demographic information about themselves, their skills, and their previous training. In each of three 6-month long general practice training terms they provide data about the practice where they work and collect data from 60 consecutive patient encounters using an online portal. Analysis of data uses standard techniques including linear and logistic regression modelling. The ReCEnT project has approval from the University of Newcastle Human Research Ethics Committee, Reference H-2009-0323.

DISCUSSION

Strengths of the study are the granular detail of clinical practice relating to patient demographics, presenting problems/diagnoses, medication decisions, investigations requested, referrals made, procedures undertaken, follow-up arranged, learning goals generated, and in-consultation help sought; the linking of the above variables to the presenting problems/diagnoses to which they pertain; and a very high response rate. The study is limited by not having information regarding severity of illness, medical history of the patient, full medication regimens, or patient compliance to clinical decisions made at the consultation. Data is analysed using standard techniques to answer research questions that can be categorised as: mapping analyses of clinical exposure; exploratory analyses of associations of clinical exposure; mapping and exploratory analyses of educational actions; mapping and exploratory analyses of other outcomes; longitudinal 'within-registrar' analyses; longitudinal 'within-program' analyses; testing efficacy of educational interventions; and analyses of ReCEnT data together with data from other sources. The study enables identification of training needs and translation of subsequent evidence-based educational innovations into specialist training of general practitioners.

Nutritional Knowledge, Confidence, Attitudes towards Nutritional Care and Nutrition Counselling Practice among General Practitioners

Nutritional care represents any practice provided by a health professional, aimed to improve the patient's health outcomes by influencing patient's dietary habits. Clearly, dietitians are the ones supposed to provide top-quality nutrition care, but their services are often inaccessible to many for various reasons. This obliges general practitioners (GPs) in primary health care to provide nutritional counselling to their patients to a certain extent. Preconditions to successful nutritional counselling are GPs with adequate nutritional knowledge, positive attitudes towards nutrition and nutritional care, self-confident and competent in nutritional counselling. Therefore, the aim of this review is to summarise currently available information on nutritional knowledge, confidence and attitudes towards nutritional care and nutrition counselling practice of GPs, as well as barriers towards provision of nutritional counselling. GPs do not consistently obtain satisfying results in nutrition knowledge assessments and their self-confidence in nutrition counselling skills varies. Studies suggest that nutritional counselling practice still has not met its full potential, and GPs frequently report various barriers that impair nutritional counselling practice. Thus, health policies that help overcome barriers and create stimulating environment for GPs to implement nutrition counselling strategies efficiently are the key to improving quality and quantity of nutritional counselling.

The Underuse of Medicare's Prevention and Coordination Codes in Primary Care : A Cross-Sectional and Modeling Study

BACKGROUND

Efforts to better support primary care include the addition of primary care-focused billing codes to the Medicare Physician Fee Schedule (MPFS).

OBJECTIVE

To examine potential and actual use by primary care physicians (PCPs) of the prevention and coordination codes that have been added to the MPFS.

DESIGN

Cross-sectional and modeling study.

SETTING

Nationally representative claims and survey data.

PARTICIPANTS

Medicare patients.

MEASUREMENTS

Frequency of use and estimated Medicare revenue involving 34 billing codes representing prevention and coordination services for which PCPs could but do not necessarily bill.

RESULTS

Eligibility among Medicare patients for each service ranged from 8.8% to 100%. Among eligible patients, the median use of billing codes was 2.3%, even though PCPs provided code-appropriate services to more patients, for example, to 5.0% to 60.6% of patients eligible for prevention services. If a PCP provided and billed all prevention and coordination services to half of all eligible patients, the PCP could add to the practice's annual revenue $124 435 (interquartile range [IQR], $30 654 to $226 813) for prevention services and $86 082 (IQR, $18 011 to $154 152) for coordination services.

LIMITATION

Service provision based on survey questions may not reflect all billing requirements; revenues do not incorporate the compliance, billing, and opportunity costs that may be incurred when using these codes.

CONCLUSION

Primary care physicians forego considerable amounts of revenue because they infrequently use billing codes for prevention and coordination services despite having eligible patients and providing code-appropriate services to some of those patients. Therefore, creating additional billing codes for distinct activities in the MPFS may not be an effective strategy for supporting primary care.

PRIMARY FUNDING SOURCE

National Institute on Aging.

Association between primary care appointment lengths and subsequent ambulatory reassessment, emergency department care, and hospitalization: a cohort study

Background

To meet increasing demand, healthcare systems may leverage shorter appointment lengths to compensate for a limited supply of primary care providers (PCPs). Limiting the time spent with patients when evaluating acute health needs may adversely affect quality of care and increase subsequent healthcare utilization; however, the impact of brief duration appointments on healthcare utilization in the United States has not been examined. This study aimed to assess for potential inferiority of shorter (15-min) primary care appointments compare to longer (≥ 30-min appointments) with respect to downstream healthcare utilization within 7 days of the initial appointment.

Methods

We performed a retrospective cohort study using electronic health record (EHR), billing, and administrative scheduling data from five primary care practices in Midwest United States. Adult patients seen for acute Evaluation & Management visits between 10/1/2015 and 9/30/2017 were included. Patients scheduled for 15-min appointments were propensity score matched to those scheduled for ≥ 30-min. Multivariate regression models examined the effects of appointment length on repeat primary care visits, emergency department (ED) visits, hospitalizations, and diagnostic services within 7 days following the visit. Models were adjusted for baseline patient, visit, and provider characteristics. A non-inferiority approach was employed.

Results

We identified 173,758 total index visits (6.5% 15-min, 93.5% ≥ 30-min). 11,222 15-min appointments were matched to a comparable ≥ 30-min visit. Longer appointments were more frequent among trainee physicians, patients with limited English proficiency, and patients with more comorbidities. There was no significant effect of scheduled appointment length on the incidence of repeat primary care visits (OR = 0.983, CI: 0.873, 1.106) or ED visits (OR = 0.856, CI: 0.700, 1.047). Shorter appointments were associated with lower rates of subsequent hospitalizations (OR = 0.689, CI: 0.504, 0.941), laboratory services (OR = 0.682, CI: 0.643, 0.724), and diagnostic imaging services (OR = 0.499, CI: 0.466, 0.534). None of the non-inferiority thresholds were exceeded.

Conclusions

For select indications and select low risk patients, shorter duration appointments may be a non-inferior option for scheduling of patient care that will not result in greater downstream healthcare utilization. These findings can help inform healthcare delivery models and triage processes as health systems and payers re-examine how to best deliver care to growing patient populations.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-022-01644-8.

BABEL (Better tArgeting, Better outcomes for frail ELderly patients) advance care planning: a comprehensive approach to advance care planning in nursing homes: a cluster randomised trial

Background

Nursing home (NH) residents should have the opportunity to consider, discuss and document their healthcare wishes. However, such advance care planning (ACP) is frequently suboptimal.

Objective

Assess a comprehensive, person-centred ACP approach.

Design

Unblinded, cluster randomised trial.

Setting

Fourteen control and 15 intervention NHs in three Canadian provinces, 2018–2020.

Subjects

713 residents (442 control, 271 intervention) aged ≥65 years, with elevated mortality risk.

Methods

The intervention was a structured, \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{upgreek} \usepackage{mathrsfs} \setlength{\oddsidemargin}{-69pt} \begin{document} }{}$\sim$\end{document}60-min discussion between a resident, substitute decision-maker (SDM) and nursing home staff to: (i) confirm SDMs’ identities and role; (ii) prepare SDMs for medical emergencies; (iii) explain residents’ clinical condition and prognosis; (iv) ascertain residents’ preferred philosophy to guide decision-making and (v) identify residents’ preferred options for specific medical emergencies. Control NHs continued their usual ACP processes. Co-primary outcomes were: (a) comprehensiveness of advance care planning, assessed using the Audit of Advance Care Planning, and (b) Comfort Assessment in Dying. Ten secondary outcomes were assessed. P-values were adjusted for all 12 outcomes using the false discovery rate method.

Results

The intervention resulted in 5.21-fold higher odds of respondents rating ACP comprehensiveness as being better (95% confidence interval [CI] 3.53, 7.61). Comfort in dying did not differ (difference = −0.61; 95% CI −2.2, 1.0). Among the secondary outcomes, antimicrobial use was significantly lower in intervention homes (rate ratio = 0.79, 95% CI 0.66, 0.94).

Conclusions

Superior comprehensiveness of the BABEL approach to ACP underscores the importance of allowing adequate time to address all important aspects of ACP and may reduce unwanted interventions towards the end of life.

Primary Care Access During the COVID-19 Pandemic: a Simulated Patient Study

BACKGROUND

Primary care practices have experienced major strains during the COVID-19 pandemic, such that patients newly seeking care may face potential barriers to timely visits.

OBJECTIVE

To quantify availability and wait times for new patient appointments in primary care and to describe how primary care practices are guiding patients with suspected COVID-19.

DESIGN

Trained callers conducted simulated patient calls to 800 randomly sampled primary care practices between September 14, 2020, and September 28, 2020.

PARTICIPANTS

We extracted complete primary care physician listings from large commercial insurance networks in four geographically dispersed states between September 10 and 14, 2020 (n=11,521). After excluding non-physician providers and removing duplicate phone numbers, we identified 2705 unique primary care physician practices from which we randomly sampled 200 practices in each region.

MAIN MEASURES

Primary care appointment availability, median wait time in days, and practice guidance to patients suspecting COVID-19 infection.

KEY RESULTS

Among 56% of listed practices that had accurate contact information listed in the directory, 84% offered a new patient in-person or virtual appointment. Median wait time was 10 days (IQR 3-26 days). The most common guidance in case of suspected COVID-19 was clinician consultation, which was offered in 41% of completed calls. Callers were otherwise directed to on-site testing (14%), off-site testing (24%), a COVID-19 hotline (8%), or an urgent care/emergency department (12%), while 2% of practices had no guidance to offer.

CONCLUSIONS

Despite resource constraints, most reachable primary care practices offered timely new patient appointments as well as direct COVID-19 care. Pandemic mitigation strategies should account for and support the central role of primary care practices in the community-based pandemic response.

National Trends and Outcomes Associated With Presence and Type of Usual Clinician Among Older Adults With Multimorbidity

IMPORTANCE

Declining primary care visit rates and increasing specialist visit rates among older adults with multimorbidity raise questions about the presence, specialty, and outcomes associated with usual clinicians of care for these adults.

OBJECTIVE

To examine trends in the presence and specialty of usual clinicians and the association with preventive care receipt and spending.

DESIGN, SETTING, AND PARTICIPANTS

This survey study used repeated cross-sectional analyses of Medicare Current Beneficiary Survey data from 2010, 2013, and 2016. Participants were community-dwelling Medicare Advantage and traditional Medicare members with at least 2 chronic conditions. Data were analyzed from March 1, 2020, to February 5, 2021.

MAIN OUTCOMES AND MEASURES

Trends and factors associated with self-reported usual clinician presence and specialty. Multivariable regression was used to examine associations between usual clinician presence and specialty with preventive care receipt and spending, controlling for respondent sociodemographic and clinical characteristics.

RESULTS

A total of 25 490 unweighted respondent-years were examined, representing 90 324 639 respondent-years across the United States. Overall, 58.4% of respondent-years belonged to women, and the mean (SD) age of respondents was 77.5 (7.5) years. From 2010 to 2016, those reporting usual clinicians dropped from 94.2% to 91.0% (P < .001). Across study years, respondents were more likely to report a usual clinician if they were women (adjusted marginal difference [AMD], 2.5 percentage points; 95% CI, 1.5-3.5 percentage points) or had higher income (≥$50 000 vs <$15 000: AMD, 2.2 percentage points; 95% CI, 1.1-3.4 percentage points) and less likely if they were Black beneficiaries (vs White: AMD, -2.8 percentage points; 95% CI, -4.3 to -1.3 percentage points) or had traditional Medicare (vs Medicare Advantage: AMD, -3.2 percentage points; 95% CI. -4.1 to -2.3 percentage points). Among 23 279 respondents with usual clinicians, those reporting specialists as their usual clinicians decreased from 5.3% to 4.1% (P < .001). Across the study period, respondents were more likely to report specialists as their usual clinicians if they had traditional Medicare (vs Medicare Advantage: AMD, 2.3 percentage points; 95% CI, 1.6 to 2.9 percentage points), were Black or non-White Hispanic (Black vs White: AMD, 1.5 percentage points; 95% CI, 0.2 to 2.8 percentage points; non-White Hispanic vs White: AMD, 3.8 percentage points; 95% CI, 1.9 to 5.7 percentage points), or lived in the Northeast (vs Midwest: AMD, 3.6 percentage points; 95% CI, 2.1 to 5.2 percentage points). Compared with those without usual clinicians, respondents with usual clinicians were more likely to receive all examined preventive services, such as cholesterol screening (AMD, 6.7 percentage points; 95% CI, 5.4 to 8.1 percentage points) and influenza vaccines (AMD, 11.6 percentage points; 95% CI, 9.2 to 14.0 percentage points). Among respondents with usual clinicians, those reporting specialist usual clinicians (vs primary care) were less likely to receive influenza vaccines (AMD, -5.6 percentage points; 95% CI, -9.2 to -2.1).

CONCLUSIONS AND RELEVANCE

In this study, older adults with multimorbidity were less likely to have a usual clinician over the study period, with potential implications for preventive care receipt. Our results suggest a key role for usual clinicians, especially primary care clinicians, in vaccination uptake for this population.

Evaluation of the functional goal-setting and self-management tool for osteoarthritis, a patient-centred tool to improve osteoarthritis care

OBJECTIVE

Recent American College of Rheumatology guidelines emphasise functional improvement as part of osteoarthritis (OA) management. We developed and evaluated a tool to promote provider and patient engagement in functional goal setting in OA care.

METHODS

We developed the Functional Goal-setting And Self-management Tool (FAST-OA) with clinician input and pilot tested it in two US outpatient clinics. Baseline and end-of-project surveys addressed attitudes toward incorporating function into care and tool evaluation. We analysed survey data descriptively.

RESULTS

Nineteen providers and 49 patients completed surveys. At baseline, both groups endorsed the importance of functional assessment and goal setting. Providers perceived challenges to patients' ability to communicate about function. Both patients and providers highly valued the FAST-OA to promote collaborative discussion and prioritising function. More than half of both groups agreed that they would recommend it to others. End-of-project results suggested changes in provider attitudes toward patients' ability to communicate functional progress. While participants valued the FAST-OA, streamlining content may foster ongoing use.

CONCLUSION

This pilot study illustrates the potential of a function-focused, patient-facing tool to introduce self-management goal-setting strategies into busy clinical workflow, foster the provider-patient relationship, and encourage alignment with guidelines. These results can inform tailoring of tools for use in practice and to address needs of patients and providers optimally.

Defining the "New Normal" in Primary Care

Health care organizations in the United States have transformed at an unprecedented rate since March 2020 due to COVID-19, most notably with a shift to telemedicine. Despite rapidly adapting health care delivery in light of new safety considerations and a shifting insurance landscape, primary care offices across the country are facing drastic decreases in revenue and potential bankruptcy. To survive, primary care's adaptations will need to go beyond virtual versions of traditional office visits. Primary care is faced with a chance to redefine what it means to care for and support patients wherever they are. This opportunity to shape the "new normal" is a critical step for primary care to meet its full potential to lead a paradigm shift to patient-centered health care reform in America during this time when we need it most.

Shared Clinical Decision-Making Recommendations for Adult Immunization: What Do Physicians Think?

BACKGROUND

In 2019, the Advisory Committee on Immunization Practices (ACIP) incorporated the terminology "shared clinical decision-making" (SDM) into recommendations for two adult vaccines.

OBJECTIVE

To assess among general internal medicine physicians (GIMs) and family physicians (FPs) nationally (1) attitudes about and experience with ACIP SDM recommendations, (2) knowledge of insurance reimbursement for vaccines with SDM recommendations, (3) how SDM recommendations are incorporated into vaccine forecasting software, and (4) physician and practice characteristics associated with not knowing how to implement SDM.

DESIGN

Survey conducted in October 2019-January 2020 by mail or internet based on preference.

PARTICIPANTS

Networks of GIMs and FPs recruited from American College of Physicians (ACP) and American Academy of Family Physicians (AAFP) who practice ≥ 50% in primary care. Post-stratification quota sampling performed to ensure networks similar to ACP and AAFP memberships.

MAIN MEASURES

Responses on 4-point Likert scales (attitudes/experiences), true/false options (knowledge), and categorical response options (forecasting). Multivariable modeling with outcome of "not knowing how to implement SDM" conducted.

KEY RESULTS

Response rate was 64% (617/968). Most physicians strongly/somewhat agreed SDM requires more time than routine recommendations (90%FP; 95%GIM, p = 0.02) and that they need specific talking points to guide SDM discussions (79%FP; 84%GIM, p = NS). There was both support for SDM recommendations for certain vaccines (81%FP; 75%GIM, p = 0.06) and agreement that SDM creates confusion (64%FP; 76%GIM, p = 0.001). Only 41%FP and 43%GIM knew vaccines recommended for SDM would be covered by most health insurance. Overall, 38% reported SDM recommendations are displayed as "recommended" and 23% that they did not result in any recommendation in forecasting software. In adjusted multivariable models, GIMs [risk ratio 1.44 (1.15-1.81)] and females [1.28 (1.02-1.60)] were significantly associated with not knowing how to implement SDM recommendations CONCLUSIONS: To be successful in a primary care setting, SDM for adult vaccination will require thoughtful implementation with decision-making support for patients and physicians.

Improving Readiness to Manage Intimate Partner Violence in Family Medicine Clinics by Collaboration With a Community Organization

Background and Objectives

Primary care clinicians are in a unique position to address intimate partner violence (IPV) in routine clinical practice. The purpose of this study was to improve clinician readiness to identify and manage IPV in four family medicine residency practice sites on the west side of Chicago by partnering with a local domestic violence organization.

Methods

Practice sites included three federally qualified health centers and one hospital-based office. Eligible clinicians included resident and faculty physicians, nurse practitioners, and certified nurse midwives. We assessed readiness using the validated Physician Readiness to Manage Intimate Partner Violence Survey (PREMIS). We used initial survey results (n=53, 73%) to develop a targeted clinician educational intervention by a community organization. We administered the PREMIS tool postintervention at 1 and 6 months, measuring perceived and actual knowledge, preparedness, and practice issues. We performed comparison statistics to assess aggregate change.

Results

PREMIS response rates were n=53 (72%), n=32 (47%), and n=36 (49%), for preintervention, 1, and 6 months postintervention, respectively. Mean clinician preparedness score improved significantly at 1 and 6 months (P<.001, P<.009). Mean self-perceived knowledge score improved significantly at 1 month (P<.001) and trended toward improvement at 6 months (P=.07). Actual knowledge trended toward improvement at 1 month (P=.07) and after 6 months (P=.05). Mean practice issues scores did not improve significantly.

Conclusions

Participation in a 45-minute targeted educational intervention improved clinician readiness to manage IPV. Collaborating with a community partner builds a relationship for further referrals and advocacy for patients.

Characteristics of US Adults Who Would Be Recommended for Lifestyle Modification Without Antihypertensive Medication to Manage Blood Pressure

BACKGROUND

The 2017 American College of Cardiology / American Heart Association Guideline for blood pressure (BP) management newly classifies millions of Americans with elevated BP or stage 1 hypertension for recommended lifestyle modification alone (without pharmacotherapy). This study characterized these adults, including their cardiovascular disease risk factors, barriers to lifestyle modification, and healthcare access.

METHODS

This cross-sectional study examined nationally representative National Health and Nutrition Examination Survey data, 2013-2016, on 10,205 US adults aged ≥18, among whom 2,081 had elevated BP or stage 1 hypertension and met 2017 ACC/AHA BP Guideline criteria for lifestyle modification alone.

RESULTS

An estimated 22% of US adults (52 million) would be recommended for lifestyle modification alone. Among these, 58% were men, 43% had obesity, 52% had low-quality diet, 95% consumed excess sodium, 43% were physically inactive, and 8% consumed excess alcohol. Many reported attempting lifestyle changes (range: 39%-60%). Those who reported receiving health professional advice to lose weight (adjusted prevalence ratio 1.21, 95% confidence interval 1.06-1.38), reduce sodium intake (2.33, 2.00-2.72), or exercise more (1.60, 1.32-1.95) were significantly more likely to report attempting changes. However, potential barriers to lifestyle modification included 28% of adults reporting disability, asthma, or arthritis. Additionally, 20% had no health insurance and 22% had no healthcare visits in the last year.

CONCLUSIONS

One-fifth of US adults met 2017 ACC/AHA BP Guideline criteria for lifestyle modification alone, and many reported attempting behavior change. However, barriers exist such as insurance gaps, limited access to care, and physical impairment.

Model Homes: Evaluating Approaches to Patient-centered Medical Home Implementation

BACKGROUND

The patient-centered medical home (PCMH) model has been widely adopted, but the evidence on its effectiveness remains mixed. One potential explanation for these mixed findings is variation in how the model is implemented by practices.

OBJECTIVE

To identify the impact of different approaches to PCMH adoption on health care utilization in a long-term, geographically diverse sample of patients.

DESIGN

Difference-in-differences evaluation of PCMH impact on cost and utilization.

SUBJECTS

A total of 5,314,284 patient-year observations from the HealthCore Integrated Research Database, and 5943 practices which adopted the PCMH model in 14 states between 2011 and 2015.

INTERVENTION

PCMH adoption, as defined by the National Committee for Quality Assurance.

MEASUREMENTS

Six claims-based utilization measures, plus total health care expenditures. We employ hierarchical clustering to organize practices into groups based on their PCMH capabilities, then use generalized difference-in-differences models with practice or patient fixed effects to estimate the effect of PCMH recognition (overall and separately by the groups identified by the clustering algorithm) on utilization.

RESULTS

PCMH adoption was associated with a >8% reduction in total expenditures. We find significant reductions in emergency department utilization and outpatient care, and both lab and imaging services. In our by-group results we find that while the reduction in outpatient care is significant across all 3 groups, the reduction in emergency department utilization is driven entirely by 1 group with enhanced electronic communications.

CONCLUSION

The PCMH model has significant impact on patterns of health care utilization, especially when heterogeneity in implementation is accounted for in program evaluation.

Measuring Primary Care Exam Length Using Electronic Health Record Data

BACKGROUND

Physicians' time with patients is a critical input to care, but is typically measured retrospectively through survey instruments. Data collected through the use of electronic health records (EHRs) offer an alternative way to measure visit length.

OBJECTIVE

To measure how much time primary care physicians spend with their patients, during each visit.

RESEARCH DESIGN

We used a national source of EHR data for primary care practices, from a large health information technology company. We calculated exam length and schedule deviations based on timestamps recorded by the EHR, after implementing sequential data refinements to account for non-real-time EHR use and clinical multitasking. Observational analyses calculated and plotted the mean, median, and interquartile range of exam length and exam length relative to scheduled visit length.

SUBJECTS

A total of 21,010,780 primary care visits in 2017.

MEASURES

We identified primary care visits based on physician specialty. For these visits, we extracted timestamps for EHR activity during the exam. We also extracted scheduled visit length from the EHR's practice management functionality.

RESULTS

After data refinements, the average primary care exam was 18.0 minutes long (SD=13.5 min). On average, exams ran later than their scheduled duration by 1.2 minutes (SD=13.5 min). Visits scheduled for 10 or 15 minutes were more likely to exceed their allotted time than visits scheduled for 20 or 30 minutes.

CONCLUSIONS

Time-stamped EHR data offer researchers and health systems an opportunity to measure exam length and other objects of interest related to time.

Addressing Disparities in Lung Cancer Screening Eligibility and Healthcare Access. An Official American Thoracic Society Statement

Background: There are well-documented disparities in lung cancer outcomes across populations. Lung cancer screening (LCS) has the potential to reduce lung cancer mortality, but for this benefit to be realized by all high-risk groups, there must be careful attention to ensuring equitable access to this lifesaving preventive health measure.Objectives: To outline current knowledge on disparities in eligibility criteria for, access to, and implementation of LCS, and to develop an official American Thoracic Society statement to propose strategies to optimize current screening guidelines and resource allocation for equitable LCS implementation and dissemination.Methods: A multidisciplinary panel with expertise in LCS, implementation science, primary care, pulmonology, health behavior, smoking cessation, epidemiology, and disparities research was convened. Participants reviewed available literature on historical disparities in cancer screening and emerging evidence of disparities in LCS.Results: Existing LCS guidelines do not consider racial, ethnic, socioeconomic, and sex-based differences in smoking behaviors or lung cancer risk. Multiple barriers, including access to screening and cost, further contribute to the inequities in implementation and dissemination of LCS.Conclusions: This statement identifies the impact of LCS eligibility criteria on vulnerable populations who are at increased risk of lung cancer but do not meet eligibility criteria for screening, as well as multiple barriers that contribute to disparities in LCS implementation. Strategies to improve the selection and dissemination of LCS in vulnerable groups are described.

Physician Work Hours and the Gender Pay Gap - Evidence from Primary Care

BACKGROUND

The gender gap in physician pay is often attributed in part to women working fewer hours than men, but evidence to date is limited by self-report and a lack of detail regarding clinical revenue and gender differences in practice style.

METHODS

Using national all-payer claims and data from electronic health records, we conducted a cross-sectional analysis of 24.4 million primary care office visits in 2017 and performed comparisons between female and male physicians in the same practices. Our primary independent variable was physician gender; outcomes included visit revenue, visit counts, days worked, and observed visit time (interval between the initiation and the termination of a visit). We created multivariable regression models at the year, day, and visit level after adjustment for characteristics of the primary care physicians (PCPs), patients, and types of visit and for practice fixed effects.

RESULTS

In 2017, female PCPs generated 10.9% less revenue from office visits than their male counterparts (-$39,143.2; 95% confidence interval [CI], -53,523.0 to -24,763.4) and conducted 10.8% fewer visits (-330.5 visits; 95% CI, -406.6 to -254.3) over 2.6% fewer clinical days (-5.3 days; 95% CI, -7.7 to -3.0), after adjustment for age, academic degree, specialty, and number of sessions worked per week, yet spent 2.6% more observed time in visits that year than their male counterparts (1201.3 minutes; 95% CI, 184.7 to 2218.0). Per visit, after adjustment for PCP, patient, and visit characteristics, female PCPs generated equal revenue but spent 15.7% more time with a patient (2.4 minutes; 95% CI, 2.1 to 2.6). These results were consistent in subgroup analyses according to the gender and health status of the patients and the type and complexity of the visits.

CONCLUSIONS

Female PCPs generated less visit revenue than male colleagues in the same practices owing to a lower volume of visits, yet spent more time in direct patient care per visit, per day, and per year. (Funded in part by the Robert Wood Johnson Foundation.).

Revisiting the Role of Physicians in Assisted Living and Residential Care Settings

As the United States population ages, a higher share of adults is likely to use long-term services and supports. This change increases physicians' need for information about assisted living and residential care (AL/RC) settings, which provide supportive care and housing to older adults. Unlike skilled nursing facilities, states regulate AL/RC settings through varying licensure requirements enforced by state agencies, resulting in differences in the availability of medical and nursing services. Where some settings provide limited skilled nursing care, in others, residents rely on resident care coordinators, or their own physicians to oversee chronic conditions, medications, and treatments. The following narrative review describes key processes of care where physicians may interact with AL/RC operators, staff, and residents, including care planning, managing Alzheimer's disease and related conditions, medication management, and end-of-life planning. Communication and collaboration between physicians and AL/RC operators are a crucial component of care management.