Ambulatory care provided by office-based specialists in the United States

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.

Buprenorphine deregulation as an opioid crisis policy response - A comparative analysis between France and the United States

BACKGROUND

In passing the Maintstreaming Addiction Treatment Act, the United States has abolished its federal X waiver, considered a major barrier to the wider buprenorphine prescribing needed to respond to opioid-related harms. Advocates for this policy have drawn on the French response of deregulating buprenorphine prescribing to address increasing overdose mortality around the turn of the millennium. So far, such policy advocacy has incompletely accounted for contextual and health system differences between the two countries.

METHODS

Using the health system dynamics framework, this analysis compares France from 1995 to 2003 (the relevant period of buprenorphine reform) to the US from 2018 until today (the comparison period to explore potential impacts of reform). We used it to guide examination of a) contextual issues relating to opioid use epidemiology and b) health system factors including prescriber supply, sector organization, and insurance coverage for primary care to draw relevant policy learning for the contemporary US.

RESULTS

We identified that the US had a 22.5-fold higher mortality rate and a 2.3-fold higher opioid use disorder (OUD) rate compared to France, despite having rates of prescribed buprenorphine per-capita higher than, and per-person with OUD comparable to, than that of France. These wide gulfs between the scales and nature of the problems between France and the US suggest that relaxing restrictions on buprenorphine prescribing through abolishing the X waiver will be insufficient for achieving hoped-for reductions in overdose mortality.

CONCLUSION

Health system strengthening with a focus on improvements in primary care prescriber supply, coverage, and coordination are likely higher yield policy complements to relaxing buprenorphine regulation. Such an approach would better prepare the US to adapt to ongoing dynamics and uncertainties in the opioid crisis and to optimize the already relatively high levels of buprenorphine prescribing.

Racial/Ethnic Residential Segregation, Neighborhood Health Care Provision, and Choice of Pediatric Health Care Provider Across the USA

Much research has been conducted that demonstrates a link between racial/ethnic residential segregation and health care outcomes. We suggest that minority segregated neighborhoods may have diminished access to organizations and that this differential access may contribute to differences in health care outcomes across communities. We analyze this specifically using the case of pediatric health care provider choice. To examine this association, we estimate a series of multinomial logistic regression models using restricted data with ZIP code level geoidentifiers from the 2011-2012 National Survey of Children's Health (NSCH). We find that racial/ethnic residential segregation is related to a greater reliance on non-ideal forms of health care, such as clinics, and hospital outpatient departments, instead of pediatric physician's offices. This association is at least partially attenuated by the distribution of health care facilities in the local area, physician's offices, and health care practitioners in particular. Additionally, families express greater dissatisfaction with these other forms of care compared to physician's offices, demonstrating that the lack of adequate health care provision is meaningful for health care outcomes. This study expands the literature by examining how the siting of health organizations has consequences for individuals residing within these areas.

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.

Lean Implementation for Graduating Optimally Controlled Stable Type 2 Diabetics from Endocrine Specialty Clinic Back to Primary Care

INTRODUCTION

Endocrine specialty clinics (SCs) are occupied by a high percentage of stable follow-up patients, limiting access to new patients with greater needs.

AIM

Feasibility project to improve access to diabetes SC by reducing the number of stable optimally controlled follow-up type 2 diabetic patients.

SETTING

M Health Fairview (MHFV), a hybrid network of University of Minnesota academic and Fairview Health community hospitals and clinics with affiliated providers.

PROGRAM DESCRIPTION

A team-based lean methodology quality improvement graduation program including medical assistants, nurses, physicians, and a compact with primary care (PC) was used to identify within the Endocrine clinic population the graduation-eligible optimally controlled stable type 2 diabetic patients, acclimate them to the graduation concept, engage in shared decision-making, and transition them back to PC with a warm hand-off and graduation certificate.

PROGRAM EVALUATION

Seventeen percent (58/341) of eligible patients with optimally controlled diabetes graduated by 6 months, ranging between 0 and 83% per week.

DISCUSSION

The innovation and feasibility of opening SC access through the use of a team-based graduation program to transfer stable diabetes patients back to their home clinic was demonstrated. This innovation has the potential to support health system triage of new patients to limited access specialty care.

The Effect of Delay in Care among Patients Requiring Intravitreal Injections

PURPOSE

To examine the effect of delay in care on visual acuity (VA) in patients requiring intravitreal injections (IVIs).

DESIGN

Retrospective cohort study.

PARTICIPANTS

Patients 18 years of age or older with diabetic macular edema (DME), proliferative diabetic retinopathy (PDR), or both; neovascular age-related macular degeneration (nAMD); or retinal vein occlusion (RVO) scheduled to see a retina specialist during the mandated lockdown period (March 14 - May 4, 2020 [the coronavirus disease 2019 period]) and who had received an IVI in the 12 weeks prior.

METHODS

Chart review was performed and demographics, diagnoses, procedures, and VA were recorded.

MAIN OUTCOME MEASURES

VA in patients who completed, canceled, and no-showed for the scheduled visit.

RESULTS

Of the 1041 total patients, 620 (60%) completed the scheduled visit, whereas 376 (36%) canceled and 45 (4%) no-showed. In patients who missed the visit, the average delay in care was 5.34 weeks. In those who missed a visit, VA was assessed at the subsequent visit. Patients who canceled a visit were older, and patients who no-showed had lower baseline vision (mean Early Treatment Diabetic Retinopathy Study letters ± standard error [SE]: no-show, 53.27 ± 3.21 letters; canceled, 60.79 ± 1.11 letters; and completed, 62.81 ± 0.84 letters; P = 0.0101) and were more likely to have DME, PDR, or both (no-show, 13 patients [29%]; canceled, 56 patients [16%]; completed, 81 patients [13%]; P = 0.0456). Patients who missed a visit lost vision as compared with the patients who completed one (no-show, -5.024 ± 1.88 letters; canceled, -1.633 ± 0.65 letters; completed, 0.373 ± 0.50 letters; P = 0.0028). Patients with DME, PDR, or both (-3.48 ± 1.95 letters vs. 2.71 ± 1.75 letters; P = 0.0203), with RVO (-3.22 ± 1.41 letters vs. 0.95 ± 1.23 letters; P = 0.0230), and, to lesser degree, with nAMD (-1.23 ± 0.70 letters vs. -0.24 ± 0.56 letters; P = 0.2679) lost vision compared with patients with same diagnoses who completed the scheduled visit.

CONCLUSIONS

In patients requiring IVIs, a delay in care of 5.34 weeks resulted in vision loss. It was seen in all patients, but was more prominent in patients with DME, PDR or both and RVO. Further studies are necessary to examine whether these vision changes persist over a longer duration.

A telemedicine strategy to reduce waiting lists and time to specialist care: A retrospective cohort study

Introduction

The demand for specialty care is rising worldwide. In the state of Rio Grande do Sul, Brazil, more than 150,000 people were waiting for specialist consultations in 2013. A telemedicine programme (RegulaSUS) developed referral protocols, audited waitlisted cases, authorised/prioritised referrals by risk and discuss deferred cases primary-care physician. This study assesses the effectiveness of RegulaSUS.

Methods

A retrospective cohort analysis with contemporaneous controls was performed from June 2014 to June 2016. Six medical specialties included in RegulaSUS (50,185 patients) were compared to 50,124 control patients waitlisted according to the usual routine (scheduled for specialty consultation at the next available date). The groups were matched (1:1) by semester and year of waitlisting and by the specialty demand-to-supply ratio. Primary outcomes were referral-to-consultation time and number of waitlisted patients.

Results

The mean referral-to-consultation time was 584.8 days in the intervention group and 607.0 days in controls ( p<0.001). For specialties regulated by RegulaSUS, the mean referral-to-consultation time was 237.6 days for higher-risk patients. At the end of the observation, 26,708 control patients had been unlisted compared to 31,050 patients in the intervention group (reduction of 53.5% vs. 61.9%, respectively; p<0.001). The number of cancelled referrals was lower in the control group ( n=14,403; 28.7%) than in the intervention group ( n=16,387; 32.7%; p<0.001).

Discussion

Telemedicine support for primary care effectively decreased the time to specialty consultation, reduced the number of waitlisted patients and allowed sicker patients to reach a specialist faster.

Use of Primary Care and Specialty Providers: Findings from the Medical Expenditure Panel Survey

BACKGROUND

A comprehensive picture of how the US population engages in specialty care use is lacking, even though redesign models focused on specialty care are becoming more popular.

OBJECTIVE

To describe the type of provider, primary care or specialist, most often seen by individuals, to test associations between type of provider most often seen and insurance coverage, and to test associations between the number of generalist and specialist visits and insurance coverage.

DESIGN

Cross-sectional analysis of 2013-2016 Medicaid Expenditure Panel Survey. Logistic and negative binomial models were used in multivariate regression modeling.

PARTICIPANTS

Depending on the analysis, the study samples include between 71,402 and 79,518 US residents.

MAIN MEASURES

Individuals' provider type most often seen, primary care visits, and specialist visits were reported.

KEY RESULTS

More than half of the sample (55%) predominantly visited primary care providers (or generalists), and 36% predominantly visited specialists. Among individuals primarily visiting generalists, 80% visited only one type of primary care provider, and 24% also visited one or more specialists. Among individuals primarily visiting specialists, 48% visited only one type of specialist, and 47% did not visit any generalists in the year. Among Medicare enrollees, 50% predominantly visited specialists, and 40% predominantly visited generalists. Medicare enrollment was associated with greater odds of predominantly visiting specialists (p < 0.05), and Medicare-Medicaid enrollment and having no insurance were associated with lower odds of predominantly visiting specialists (p < 0.05). Medicare enrollment was associated with 13% more generalist visits and 35% more specialist visits, and Medicare-Medicaid enrollment was associated with 38% more generalist visits and 15% more specialist visits (all p < 0.05).

CONCLUSIONS

Given the overall frequency of specialty care use and the reliance on multiple specialists in any given year, particularly among Medicare enrollees, public payers are uniquely positioned to promote specialty care redesign and champion improved coordination between specialists.

Perspectives of adolescent girls with cystic fibrosis and parents on disease-specific sexual and reproductive health education

INTRODUCTION

Adolescent girls with cystic fibrosis (CF) face significant disease-specific sexual and reproductive health (SRH) concerns that are not typically addressed in routine clinical care. Additionally, there is a paucity of developmentally appropriate CF-specific SRH educational resources for this population. The goal of this study was to explore patient and parent attitudes toward SRH educational resources for adolescent girls with CF.

METHODS

Adolescent girls ages 13-18 years with CF and parents of daughters ages 10-18 years with CF completed individual, semi-structured interviews regarding their experiences and preferences around CF-specific SRH education and care. To facilitate discussion, participants provided feedback on the format and design of existing SRH educational resources. Qualitative analysis was conducted using a thematic analysis approach.

RESULTS

We interviewed 26 participants (14 parents and 12 patients). The majority reported they had never discussed SRH in the CF care setting. All participants preferred a comprehensive, online patient educational resource complemented by real patient stories and interactive components. Participants noted that such resources should create a sense of normalcy and community around CF and female SRH. Most desired more frequent communication around SRH between adolescent girls with CF and their healthcare providers as a way to promote SRH knowledge, decision making, and health outcomes.

DISCUSSION

Adolescent girls with CF and their parents desire an online patient educational resource that normalizes SRH and enhances patient-provider communication around these topics. Creation of developmentally appropriate resources would facilitate improved health outcomes around this aspect of comprehensive care in CF.

Transitioning Patients From Specialty Care to Primary Care: What We Know and What We Can Do

Growing demand for specialty care has resulted in longer wait times for appointments, particularly at US academic referral centers. A proportion of specialty visits are for routine follow-up care of stable problems, and there is evidence that primary care providers are willing and able to take responsibility for a significant proportion of these patients. However, little is known about how to transition care back to a referring primary care clinician in a manner that is acceptable to everyone involved. In this article, we describe social, legal, and financial barriers to effective care transition and propose communication strategies to overcome them.

Referral system in rural Iran: improvement proposals

Because of insufficient communication between primary health care providers and specialists, which leads to inefficiencies and ineffectiveness in rural population health outcomes, to implement a well-functioning referral system is one of the most important tasks for some countries. Using purposive and snowballing sampling methods, we included health experts, policy-makers, family physicians, clinical specialists, and experts from health insurance organizations in this study according to pre-determined criteria. We recorded all interviews, transcribed and analyzed their content using qualitative methods. We extracted 1,522 individual codes initially. We also collected supplementary data through document review. From reviews and summarizations, four main themes, ten subthemes, and 24 issues emerged from the data. The solutions developed were: care system reform, education system reform, payment system reform, and improves in culture-building and public education. Given the executive experience, the full familiarity, the occupational and geographical diversity of participants, the solutions proposed in this study could positively affect the implementation and improvement of the referral system in Iran. The suggested solutions are complementary to each other and have less interchangeability.

Gastroenterologist and primary care perspectives on a post-endoscopy discharge policy: impact on clinic wait times, provider satisfaction and provider workload

Background

To reduce unnecessary ambulatory gastroenterology (GI) visits and increase access to GI care, San Francisco Health Network gastroenterologists and primary care providers implemented guidelines in 2013 that discharged certain patients back to primary care after endoscopy with formal written recommendations. This study assesses the longer-term impact of this policy on GI clinic access, workflow, and provider satisfaction.

Methods

An email-based survey assessed gastroenterologist and primary care provider (PCP) opinions about the discharge process. Administrative data and chart review were used to assess clinic access, intervention fidelity, and re-referral rates.

Results

102/299 (34%) of PCPs and 5/7 (71%) of gastroenterologists responded to the survey. 74% of PCPs and 100% of gastroenterologists were satisfied or very satisfied with the discharge process. 80% of gastroenterologists believed the discharge process decreased their workload, while 53.5% of primary care providers believed it increased their workload. 6.7% of patients discharged to primary care in 2013 had re-referrals to GI. Wait time for the third-next-available new outpatient GI clinic appointment had previously decreased from 158 days (2012, pre-intervention) to 74 days (2013, post-intervention). In 2015, wait time was 19 days (p < 0.001 for 2012 vs. 2015).

Conclusions

Primary care providers and gastroenterologists are satisfied with an intervention to discharge patients from gastroenterology to primary care after certain endoscopic procedures, although this conclusion is limited by a relatively low PCP survey response rate. Discharging appropriate patients using consensus criteria from the gastroenterology clinic was instrumental in sustainably reducing clinic wait times with low re-referral rates.

Electronic supplementary material

The online version of this article (10.1186/s12913-017-2819-6) contains supplementary material, which is available to authorized users.

Medicare Home Visit Program Associated With Fewer Hospital And Nursing Home Admissions, Increased Office Visits

Clinical home visit programs for Medicare beneficiaries are a promising approach to supporting aging in place and avoiding high-cost institutional care. Such programs combine a comprehensive geriatric assessment by a clinician during a home visit with referrals to community providers and health plan resources to address uncovered issues. We evaluated UnitedHealth Group's HouseCalls program, which has been offered to Medicare Advantage plan members in Arkansas, Georgia, Missouri, South Carolina, and Texas since January 2008. We found that, compared to non-HouseCalls Medicare Advantage plan members and fee-for-service beneficiaries, HouseCalls participants had reductions in admissions to hospitals (1 percent and 14 percent, respectively) and lower risk of nursing home admission (0.67 percent and 1.3 percent, respectively). In addition, participants' numbers of office visits--chiefly to specialists--increased 2-6 percent (depending on the comparison group). The program's effects on emergency department use were mixed. These results indicate that a thorough home-based clinical assessment of a member's health and home environment combined with referral services can support aging in place, promote physician office visits, and preempt costly institutional care.

Finding the Primary Care Providers in the Specialist-Dominant Primary Care Setting of Korea: A Cluster Analysis

Objective

This study aimed to identify private clinics that have a potential to perform the role of primary care providers (PCPs) in a primary care setting in Korea where private specialists are dominant.

Methods

The 2013 National Patient Sample claim data of Health Insurance Review and Assessment Service in Korea was used. Two-step cluster analysis was performed using characteristics of private clinics, and patient and utilization characteristics of 27,797 private clinics. External validation of clusters was performed by assessing the association among clusters and outcomes of care provided by private clinics. Stability of clusters was cross-validated using discriminant analysis.

Results

The result classified more than a half of private clinics into a potential PCP cluster. These were private clinics with specialties considered to be those of primary care physicians and were more likely to be located in non-metropolitan areas than specialized PCPs were. Compared to specialized PCPs, they had a higher percentage of pediatric and geriatric patients, patients with greater disease severity, a higher percentage of patients with complex comorbidities or with simple or minor disease groups, a higher number of patients and visits, and the same or higher quality of primary care. The most important factor in explaining variations between PCP clusters was the number of simple or minor disease groups per patient.

Conclusion

This study identified potential PCPs and suggested the identifying criteria for PCPs. It will provide useful information for formulation of a primary care strengthening policy to policy makers in Korea as well as other countries with similar specialist-dominant primary care settings.

Diagnosis - the limiting focus of taxonomy

RATIONALE, AIMS AND OBJECTIVES

The focus on the diagnosis is a pivotal aspect of medical practice since antiquity. Diagnostic taxonomy helped to categorize ailments to improve medical care, and in its social sense resulted in validation of the sick role for some, but marginalization or stigmatization for others. In the medical industrial complex, diagnostic taxonomy structured health care financing, management and practitioner remuneration. However, with increasing demands from multiple agencies, there are increasing unintended and unwarranted consequences of our current taxonomies and diagnostic processes resulting from the conglomeration of underpinning concepts, theories, information and motivations.

RESULTS

We argue that the increasing focus on the diagnosis resulted in excessive compartmentalization - 'partialism' - of medical practice, diminishing medical care and being naively simplistic in light of the emerging understanding of the interconnected nature of the diseasome. The human is a complex organic system of interconnecting dynamics and feedback loops responding to internal and external forces including genetic, epigenetic and environmental attractors, rather than the sum of multiple discrete organs which can develop isolated diseases or multiple morbidities. Solutions to these unintended consequences of many contemporary health system processes involve revisiting the nature of diagnostic taxonomies and the processes of their construction. A dynamic taxonomic framework would shift to more relevant attractors at personal, clinical and health system levels recognizing the non-linear nature of health and disease. Human health at an individual, group and population level is the ability to adapt to internal and external stressors with resilience throughout the life course, yet diagnostic taxonomies are increasingly constructed around fixed anchors.

CONCLUSIONS

Understanding diagnosis as dissecting, pigeonholing or bean counting (learning by dividing) is no longer useful, the challenge for the future is to understand the big picture (learning by connecting). Diagnostic categorization needs to embrace a meta-learning approach open to human variability.

Impact of Type of Medical Specialist Involvement in Chronic Illness Care on Emergency Department Use

OBJECTIVES

Medical specialist physicians may act as either consultants or co-managers for patients managed in primary care settings. We assessed whether the type of specialist involvement affected emergency department (ED) use for patients with chronic diseases.

METHODS

In total, 709 primary care patients with arthritis, chronic obstructive pulmonary disease, diabetes or congestive heart failure were followed for one year using survey and administrative data. Multivariate logistic regressions were used to compare all-cause ED use according to specialist involvement (none, co-manager or consultant).

RESULTS

In total, 240 (34%) patients visited the ED. ED use did not differ between those with specialist involvement and those without it, either as co-managers (adjusted OR = 1.06, 95% CI = [0.61, 1.85]) or consultants (adjusted OR = 0.97, 95% CI = [0.63, 1.50]).

DISCUSSION

The type of specialist involvement is not associated with all-cause ED use in primary care patients with chronic diseases. Indications for co-management should be further investigated.

Cost Burden of Chronic Pain Patients in a Large Integrated Delivery System in the United States

OBJECTIVES

To estimate all-cause healthcare resource utilization and costs among chronic pain patients within an integrated healthcare delivery system in the United States.

METHODS

Electronic medical records and health claims data from the Henry Ford Health System were used to determine healthcare resource utilization and costs for patients with 24 chronic pain conditions. Patients were identified by ≥ 2 ICD-9-CM codes ≥ 30 days apart from January to December, 2010; the first ICD-9 code was the index event. Continuous coverage for 12 months pre- and postindex was required. All-cause direct medical costs were determined from billing data.

RESULTS

A total of 12,165 patients were identified for the analysis. After pharmacy, the most used resource was outpatient visits, with a mean of 18.8 (SD 13.2) visits per patient for the postindex period; specialty visits accounted for 59.0% of outpatient visits. Imaging was utilized with a mean of 5.2 (SD 5.5) discrete tests per patient, and opioids were the most commonly prescribed medication (38.7%). Annual direct total costs for all conditions were $386 million ($31,692 per patient; a 40% increase from the pre-index). Pharmacy costs comprised 14.3% of total costs, and outpatient visits were the primary cost driver.

CONCLUSIONS

Chronic pain conditions impose a substantial burden on the healthcare system, with musculoskeletal conditions associated with the highest overall costs. Costs appeared to be primarily related to use of outpatient services. This type of research supports integrated delivery systems as a source for assessing opportunities to improve patient outcomes and lower the costs for chronic pain patients.

Indonesian primary care physicians profile in 2011: Did practicing hours and conversion program for family medicine differentiate their services and continuing medical education activities?

BACKGROUND

In Indonesia, Family Medicine as a discipline is being developed through short courses since 12 years ago. A conversion program to become Family Physicians has been introduced recently. Among the 70,000 primary care physicians there are variety of practitioners, from new interns who start general practice to senior general practitioners. This study aims to describe the current Indonesian Primary Care Physicians (PCPs) profile which includes services provided and facilities as well as comparing the profile according to participation in the conversion program and practice hours.

METHODS

A survey was carried out by using pre-tested, semi-structured and self-administered questionnaire among Indonesian primary care physicians (PCPs) who attended ASEAN Regional Primary Care Conference in Jakarta, November 2011. The survey elicited information regarding their practice environment, services provided, equipment, investigations provided, procedures, facilities and continuing medical education (CME) activities.

RESULTS

Out of 240 PCPs participated, 65.4% (157/240) of them were family physicians and 67.1% (161/240) of them were full time practitioners (practice > 30 hours per week). Services like body mass index (BMI) measurement, substance abuse program, respiratory function test, mental health assessment, and cardiovascular assessment were provided by less than 50% of the PCPs as well as some investigations like electrocardiograph (ECG), proctoscopy, ultrasound, visual examination and funduscopy. Family Physicians significantly provided more house call services (77% vs 63%; p = 0.01), than those who are not. No other significant difference was found in the practice of the family physicians compare to non-family physicians.

CONCLUSIONS

The Indonesian PCPs were lacking in the provision of some particular medical procedures, management and follows up of acute and chronic conditions, and preventive medicine and health education. Improvement of primary health care has been seen globally as necessary effort in health systems reform and this information could provide guidance toward the efforts to improve the quality of primary care physicians in Indonesia.

When to repatriate? Clinicians' perspectives on the transfer of patient management from specialty to primary care

BACKGROUND

Subspecialty ambulatory care visits have doubled in the past 10 years and nearly half of all visits are for follow-up care. Could some of this care be provided by primary care providers (PCPs)?

OBJECTIVE

To determine how often PCPs and specialists agree that a mutual patient's condition could be managed exclusively by the PCP, and to understand PCPs' perspectives on factors that influence decisions about 'repatriation,' or the transfer of patient management to primary care.

DESIGN

A mixed method approach including paired surveys of PCPs and specialists about the necessity for ongoing specialty care of mutual patients, and interviews with PCPs about care coordination practices and reasons for differing opinions with specialists.

PARTICIPANTS

One hundred and eighty-nine PCPs and 59 physicians representing five medicine subspecialties completed paired surveys for 343 patients. Semi-structured interviews were conducted with 16 PCPs.

MEASUREMENTS

For each patient, PCPs and specialists were asked, "Could this diagnosis be managed exclusively by the PCP?"

RESULTS

Specialists and PCPs agreed that transfer to primary care was appropriate for 16% of patients, whereas 36% had specialists and PCPs who agreed that ongoing specialty care was appropriate. Specialists were half as likely as PCPs to identify patients as appropriate for transfer to primary care. PCPs identified several factors that influence the likelihood that patients will be transferred to primary care, including perceived patient preferences, limited access to physician appointments, excessive workload, inter-clinician communication norms, and differences in clinical judgment. We group these factors into two domains: 'push-back' and 'pull-back' to primary care.

CONCLUSIONS

At a large academic medical center, approximately one in six patients receiving ongoing specialty care could potentially be managed exclusively by a PCP. PCPs identified several non-clinical factors to explain continuation of specialty care when patient transfer to PCP is clinically appropriate.

Social accountability of medical schools and academic primary care training in Latin America: principles but not practice

BACKGROUND

Latin America has one of the highest rates of health disparities in the world and is experiencing a steep increase in its number of medical schools. It is not clear if medical school authorities consider social responsibility, defined as the institutional commitment to contribute to the improvement of community well-being, as a priority and if there are any organizational strategies that could reduce health disparities.

OBJECTIVE

To study the significance and relevance of social responsibility in the academic training of medical schools in Latin America.

METHODS

The study combined a qualitative thematic literature review of three databases with a quantitative design based on a sample of nine Latin American and non-Latin American countries.

RESULTS

The thematic analysis showed high agreement among academic groups on considering medical schools as 'moral agents', part of a 'social contract' and with an institutional responsibility to reduce health disparities mainly through the implementation of strong academic primary care programs. The quantitative analysis showed a significant association between higher development of academic primary care programs and lower level of health disparities by country (P = 0.028). However, the data showed that most Latin American medical schools did not prioritize graduate primary care training.

CONCLUSIONS

The study shows a discrepancy between the importance given to social responsibility and academic primary care training in Latin America and the practices implemented by medical schools. It highlights the need to refocus medical education policies in the region.

Delivering PACT-principled care: are specialty care patients being left behind?

BACKGROUND

With the reorganization of primary care into Patient Aligned Care Teams (PACT) teams, the Veteran Affairs Health System (VA) aims to ensure all patients receive care based on patient-centered medical home (PCMH) principles. However, some patients receive the preponderance of care from specialty rather than primary care clinics because of the special nature of their clinical conditions. We examined seven VA (HIV) clinics as a model to test the extent to which such patients receive PCMH-principled care.

OBJECTIVE

To examine the extent to which HIV specialty care in VA conforms to PCMH principles.

DESIGN

Qualitative study.

PARTICIPANTS

Forty-one HIV providers from seven HIV clinics and 20 patients from four of these clinics.

APPROACH

We conducted semi-structured interviews with HIV clinic providers and patients about care practices and adherence to PCMH principles. Using an iterative approach, data was analyzed using both a content analysis and an a priori, PCMH-principled coding strategy.

KEY RESULTS

Patients with HIV receive varying levels of PCMH-principled care across a range of VA HIV clinic structures. The more PCMH-principled HIV clinics largely functioned as PCMHs; patients received integrated, coordinated, comprehensive primary care within a dedicated HIV clinic. In contrast, some clinics were unable to meet the criteria of being a patient's medical home, and instead functioned primarily as a place to receive HIV-related services with limited care coordination. Patients from the less PCMH-principled clinics reported less satisfaction with their care.

CONCLUSIONS

Even in a large, integrated healthcare system, there is wide variation in patients' receipt of PCMH-principled care in specialty care settings. In order to meet the goal of having all patients receiving PCMH-principled care, there needs to be careful consideration of where primary and specialty care services are delivered and coordinated. The best mechanisms for ensuring that patients with complex medical conditions receive PCMH-principled care may need to be tailored to different specialty care contexts.

Trends and quality of care in outpatient visits to generalist and specialist physicians delivering primary care in the United States, 1997-2010

BACKGROUND

Although many specialists serve as primary care physicians (PCPs), the type of patients they serve, the range of services they provide, and the quality of care they deliver is uncertain.

OBJECTIVE

To describe trends in patient, physician, and visit characteristics, and compare visit-based quality for visits to generalists and specialists self-identified as PCPs.

DESIGN

Cross-sectional study and time trend analysis.

DATA

Nationally representative sample of visits to office-based physicians from the National Ambulatory Medical Care Survey, 1997-2010.

MAIN MEASURES

Proportions of primary care visits to generalist and specialists, patient characteristics, principal diagnoses, and quality.

KEY RESULTS

Among 84,041 visits to self-identified PCPs representing an estimated 4.0 billion visits, 91.5 % were to generalists, 5.9 % were to medical specialists and 2.6 % were to obstetrician/gynecologists. The proportion of PCP visits to generalists increased from 88.4 % in 1997 to 92.4 % in 2010, but decreased for medical specialists from 8.0 % to 4.8 %, p = 0.04). The proportion of medical specialist visits in which the physician self-identified as the patient's PCP decreased from 30.6 % in 1997 to 9.8 % in 2010 (p < 0.01). Medical specialist PCPs take care of older patients (mean age 61 years), and dedicate most of their visits to chronic disease management (51.0 %), while generalist PCPs see younger patients (mean age 55.4 years) most commonly for new problems (40.5 %). Obstetrician/gynecologists self-identified as PCPs see younger patients (mean age 38.3 p < 0.01), primarily for preventive care (54.0 %, p < 0.01). Quality of care for cardiovascular disease was better in visits to cardiologists than in visits to generalists, but was similar or better in visits to generalists compared to visits to other medical specialists.

CONCLUSIONS

Medical specialists are less frequently serving as PCPs for their patients over time. Generalist, medical specialist, and obstetrician/gynecologist PCPs serve different primary care roles for different populations. Delivery redesign efforts must account for the evolving role of generalist and specialist PCPs in the delivery of primary care.

U.S. clinicians' perspectives on less frequent routine gynecologic examinations

OBJECTIVE

With newer recommendations for less frequent cervical cancer screening, longer intervals between routine gynecologic examinations might also be considered.

METHODS

A nationally representative mailed survey of U.S. obstetrician-gynecologists (n=521, response rate 62%) was conducted in 2010-11. Clinicians were asked their views on annual gynecologic examinations and on the consequences of extending the interval from annually to every 3 years for asymptomatic patients.

RESULTS

Over two-thirds considered annual gynecologic examination very important for women in their reproductive years (69%); fewer consider it very important for women in menopause (55%). Most anticipated that shifting examinations to every 3 years would result in lower patient satisfaction (78%), contraceptive provision (74%), and patient health and well-being (74%). Decreases in clinic volume (93%) and financial reimbursement (78%) were also expected. Anticipated effects of longer intervals varied by provider characteristics, geography, and practice setting.

CONCLUSION

Obstetrician-gynecologists in the U.S. believed that longer intervals between routine examinations would have negative repercussions for patients and medical practice, but there were differences by region, practice, and personal characteristics. Redefining annual gynecologic visits as contraceptive counseling and health maintenance visits could address financial and patient volume concerns, and perspectives from patients and other providers might reveal possible benefits of less frequent gynecologic examinations.

The influence of dermatologist and primary care physician visits on melanoma outcomes among Medicare beneficiaries

BACKGROUND

Ambulatory visits to dermatologists and primary care physicians (PCPs) may improve melanoma outcomes through early detection. We sought to measure the effect of dermatologist and PCP visits on melanoma stage at diagnosis and mortality.

METHODS

We used data from the database linking Surveillance Epidemiology and End Results (SEER) and Medicare data (1994 to 2005) to examine patterns of dermatologist and PCP ambulatory visits before diagnosis for 18,884 Medicare beneficiaries with invasive melanoma or unknown stage at diagnosis. Visits were assessed during the 2-year time interval before the month of diagnosis. We examined whether dermatologist and PCP visits were associated with diagnosis of thinner melanomas (defined as local stage tumors having Breslow thickness <1 mm) and lower melanoma mortality.

RESULTS

Medicare beneficiaries visiting both a dermatologist and PCP before diagnosis had greater odds of diagnosis of a thin melanoma (adjusted odds ratio, 1.26; 95% confidence interval, 1.12-1.41) and lower melanoma mortality (adjusted hazard ratio 0.66, 95% confidence interval, 0.57-0.76) compared with those without such visits. The mortality findings were attenuated once stage at diagnosis was adjusted for in the multivariable model.

CONCLUSION

Improved melanoma outcomes among Medicare beneficiaries may depend on adequate access and use of dermatologist and PCP services.

Primary care utilization and colorectal cancer incidence and mortality among Medicare beneficiaries: a population-based, case-control study

BACKGROUND

Utilization of primary care may decrease colorectal cancer (CRC) incidence and death through greater receipt of CRC screening tests.

OBJECTIVE

To examine the association of primary care utilization with CRC incidence, CRC deaths, and all-cause mortality.

DESIGN

Population-based, case-control study.

SETTING

Medicare program.

PARTICIPANTS

Persons aged 67 to 85 years diagnosed with CRC between 1994 and 2005 in U.S. Surveillance, Epidemiology, and End Results (SEER) regions matched with control patients (n = 205,804 for CRC incidence, 54,160 for CRC mortality, and 121,070 for all-cause mortality).

MEASUREMENTS

Primary care visits in the 4- to 27-month period before CRC diagnosis, CRC incidence, CRC mortality, and all-cause mortality.

RESULTS

Compared with persons having 0 or 1 primary care visit, persons with 5 to 10 visits had lower CRC incidence (adjusted odds ratio [OR], 0.94 [95% CI, 0.91 to 0.96]) and mortality (adjusted OR, 0.78 [CI, 0.75 to 0.82]) and lower all-cause mortality (adjusted OR, 0.79 [CI, 0.76 to 0.82]). Associations were stronger in patients with late-stage CRC diagnosis, distal lesions, and diagnosis in more recent years when there was greater Medicare screening coverage. Ever receipt of CRC screening and polypectomy mediated the association of primary care utilization with CRC incidence.

LIMITATION

This study used administrative data, which made it difficult to identify potential confounders and prevented examination of the content of primary care visits.

CONCLUSION

Medicare beneficiaries with higher utilization of primary care have lower CRC incidence and mortality and lower overall mortality. Increasing and promoting access to primary care in the United States for Medicare beneficiaries may help decrease the national burden of CRC.

PRIMARY FUNDING SOURCE

American Cancer Society.

Refining physician quality indicators for screening mammography in older women: distinguishing appropriate use from overuse

OBJECTIVES

To assess the feasibility of refining physician quality indicators of screening mammography use based on patient life expectancy.

DESIGN

Retrospective population-based cohort study.

SETTING

Texas.

PARTICIPANTS

Three thousand five hundred ninety-five usual care providers (UCPs) with at least 10 female patients aged 67 and older on January 1, 2008, with an estimated life expectancy of 7 years or more (222,584 women) and at least 10 women with an estimated life expectancy of less than 7 years (90,903 women), based on age and comorbidity.

MEASUREMENTS

Screening mammography use in 2008-09 by each provider in each population.

RESULTS

The average adjusted mammography screening rates for UCPs were 31.1% for women with a life expectancy of less than 7 years and 55.2% for women with a life expectancy of 7 years or longer. For women with limited life expectancy, 3.7% of UCPs had significantly lower and 9.2% had significantly higher than average adjusted mammography screening rates. For women with longer life expectancy, 16.7% of UCPs had significantly lower and 19.7% had significantly higher than average rates. UCP adjusted screening rates were stable over time (2006-07 vs 2008-09, correlation coefficient (r) = 0.65, P < .001). There was a strong correlation between UCP screening rates for their female patients with a life expectancy of less than 7 years and 7 years or longer (r = 0.67, P < .001). Most physician characteristics associated with higher screening rates (e.g., being female and foreign trained) in women with longer life expectancy were also associated with higher screening rates in women with limited life expectancy.

CONCLUSION

Providers with high mammography screening rates for women with longer life expectancy also tend to screen women with limited life expectancy. Quality indicators for screening practice can be improved by distinguishing appropriate use from overuse based on patient life expectancy.

Where the United States spends its spine dollars: expenditures on different ambulatory services for the management of back and neck conditions

STUDY DESIGN

Serial, cross-sectional, nationally representative surveys of noninstitutionalized US adults.

OBJECTIVE

To examine expenditures on common ambulatory health services for the management of back and neck conditions.

SUMMARY OF BACKGROUND DATA

Although it is well recognized that national costs associated with back and neck conditions have grown considerably in recent years, little is known about the costs of care for specific ambulatory health services that are used to manage this population.

METHODS

We used the Medical Expenditure Panel Survey to examine adult (aged 18 yr or older) respondents from 1999 to 2008 who sought ambulatory health services for the management of back and neck conditions. We used complex survey design methods to make national estimates of mean inflation-adjusted annual expenditures on medical care, chiropractic care, and physical therapy per user for back and neck conditions.

RESULTS

Approximately 6% of US adults reported an ambulatory visit for a primary diagnosis of a back or neck condition (13.6 million in 2008). Between 1999 and 2008, the mean inflation-adjusted annual expenditures on medical care for these patients increased by 95% (from $487 to $950); most of the increase was accounted for by increased costs for medical specialists, as opposed to primary care physicians. During the study period, the mean inflation-adjusted annual expenditures on chiropractic care were relatively stable; although physical therapy was the most costly service overall, in recent years those costs have contracted.

CONCLUSION

Although this study did not explore the relative effectiveness of different ambulatory services, recent increasing costs associated with providing medical care for back and neck conditions (particularly subspecialty care) are contributing to the growing economic burden of managing these conditions.

Referral from primary to secondary care in Germany: Developing a taxonomy based on cluster analysis

Aims: Referrals from primary to secondary care may differ regarding motivation and initiative. Previous research on the frequency and variation of referrals has mostly treated referrals as homogeneous. We intended to develop a taxonomy regarding referrals from primary to secondary care in Germany that could support decision making on a macro level. Methods: We analyzed 3,988 referrals by 29 German general practitioners (GPs). GPs were asked to document all referrals during one week; in subsequent audits they stated the reasons and initiative for any referral. We postulated the following five referral types: clinical problem, shared care, administrative, patient initiated and shared cost. The data were analyzed with k-means cluster analysis. Results: We identified three of our five postulated referral types with cluster analytic techniques: shared care, clinical problem, and patient initiated. This solution accounted for 11.7% of total variance. The majority of referrals in German primary care practices were initiated by the GP, or they were part of a shared decision with patients. Conclusions: We suggest a taxonomy of referrals that might offer insights regarding the allocation of resources within the German health system. Referrals might be reduced by improved training of primary care physicians and by giving them more competencies in routine care of chronic patients.

How price responsive is the demand for specialty care?

OBJECTIVES

Outpatient visit co-payments have increased in recent years. We estimate the patient response to a price change for specialty care, based on a co-payment increase from $15 to $50 per visit for veterans with hypertension.

DESIGN, SETTING, AND PATIENTS

A retrospective cohort of veterans required to pay co-payments was compared with veterans exempt from co-payments whose nonequivalence was reduced via propensity score matching. Specialty care expenditures in 2000-2003 were estimated via a two-part mixed model to account for the correlation of the use and level outcomes over time, and results from this correlated two-part model were compared with an uncorrelated two-part model and a correlated random intercept two-part mixed model.

RESULTS

A $35 specialty visit co-payment increase had no impact on the likelihood of seeking specialty care but induced lower specialty expenditures over time among users who were required to pay co-payments. The log ratio of price responsiveness (semi-elasticity) for specialty care increased from -0.25 to -0.31 after the co-payment increase. Estimates were similar across the three models.

CONCLUSION

A significant increase in specialty visit co-payments reduced specialty expenditures among patients obtaining medications at the Veterans Affairs medical centers. Longitudinal expenditure analysis may be improved using recent advances in two-part model methods.

Managing diabetes with integrated teams: maximizing your efforts with limited time

The importance of glycemic control has been well established. In response, the American Diabetes Association has established goals for glycemic control and other cardiovascular parameters, including blood pressure and low-density and high-density lipoprotein cholesterol. However, the National Health and Nutrition Examination Survey has shown that only about half (57%) of patients with diabetes meet a glycated hemoglobin A(1c) (HbA(1c)) goal of < 7%, approximately 45% meet blood pressure and total cholesterol goals, and only 12% achieve all 3 treatment goals. While treating hyperglycemia remains the primary treatment goal, careful selection of pharmacotherapies that do not adversely affect cardiovascular risk factors or long-term glycemic control is an important consideration for patients with type 2 diabetes mellitus. During the past 5 years, the number of treatment options and the complexity of treatment guidelines for diabetes have increased markedly, which makes treatment decisions more complicated and time-consuming, and greatly impacts the workload of the primary care physicians who deliver care to the majority of this population. To provide optimal diabetes care when time and resources are limited, primary care physicians may want to enlist the support of other providers, such as nurse practitioners, physician assistants, diabetes educators, dietitians, and social and case workers. The use of team care, coupled with appropriately chosen pharmacologic therapy and patient education that fosters the development of critical thinking skills and the ability to make self-management decisions, have been shown to improve glycemic control and cardiovascular outcomes.

Advancing Primary Care in France and the United States

Primary care has been identified as key to improving health care delivery systems across the globe. France and the United States have been ranked low on scales of primary care orientation. However, each nation has developed significant approaches to structuring primary care and organizing primary care-focused systems. This article reviews those efforts and finds that both nations face similar barriers to implementing many primary care initiatives.

Primary care utilization and colorectal cancer outcomes among Medicare beneficiaries

BACKGROUND

Primary medical care may improve colorectal cancer (CRC) outcomes through increased use of CRC screening tests and earlier diagnosis. We examined the association between primary care utilization and CRC screening, stage at diagnosis, CRC mortality, and all-cause mortality.

METHODS

We conducted a retrospective cohort study of patients, aged 67 to 85 years, diagnosed as having CRC between 1994 and 2005 in the Surveillance, Epidemiology, and End Results-Medicare-linked database. Association of the number of visits to primary care physicians (PCPs) in the 3- to 27-month period before the CRC diagnosis and CRC screening, early-stage diagnosis, CRC mortality, and all-cause mortality were examined using multivariable logistic regression and Cox proportional hazards models.

RESULTS

The odds of CRC screening and early-stage diagnosis increased with increasing number of PCP visits (P < .001 for trend). Compared with persons having 0 or 1 PCP visit, patients with 5 to 10 visits had increased odds of ever receiving CRC screening at least 3 months before diagnosis (adjusted odds ratio, 2.60; 95% CI, 2.48-2.72) and early-stage diagnosis (1.35; 1.29-1.42). Persons with 5 to 10 visits had 16% lower CRC mortality (adjusted hazard ratio [AHR], 0.84; 95% CI, 0.80-0.88) and 6% lower all-cause mortality (0.94; 0.91-0.97) compared with persons with 0 or 1 visit.

CONCLUSIONS

Medicare beneficiaries with CRC have better outcomes if they have greater utilization of primary care before diagnosis. Revitalization of primary care in the United States may help strengthen the national efforts to reduce the burden of CRC.

Implementation of an electronic referral system for outpatient specialty care

Poor communication between primary care and specialists often leads to delays, inefficiencies and suboptimal patient outcomes. This study examined implementation of an electronic referral system (eReferral) that creates direct communication between primary care providers and specialist reviewers. Semi-structured interviews were conducted to assess factors affecting the success of eReferral implementation; transcripts were analyzed using qualitative methods. Primary and specialty care providers were enthusiastic about the system. Primary care providers had favorable attitudes despite a number of challenges including increased workload due to a shift in tasks from specialists and administrative personnel, poor connectivity, and insufficient hardware. System acceptance was driven by perceptions of improved access to specialty care, better appointment tracking, and improved communication between primary and specialty care providers. Synergy among development processes, implementation practices, and technical factors, including human-centered design, iterative development, a phased rollout, and an intuitive user interface, also fostered uptake of the system.

Patterns of ambulatory medical care utilization in elderly patients with special reference to chronic diseases and multimorbidity--results from a claims data based observational study in Germany

BACKGROUND

In order to estimate the future demands for health services, the analysis of current utilization patterns of the elderly is crucial. The aim of this study is to analyze ambulatory medical care utilization by elderly patients in relation to age, gender, number of chronic conditions, patterns of multimorbidity, and nursing dependency in Germany.

METHODS

Claims data of the year 2004 from 123,224 patients aged 65 years and over which are members of one nationwide operating statutory insurance company in Germany were studied. Multimorbidity was defined as the presence of 3 or more chronic conditions of a list of 46 most prevalent chronic conditions based on ICD 10 diagnoses. Utilization was analyzed by the number of contacts with practices of physicians working in the ambulatory medical care sector and by the number of different physicians contacted for every single chronic condition and their most frequent triadic combinations. Main statistical analyses were multidimensional frequency counts with standard deviations and confidence intervals, and multivariable linear regression analyses.

RESULTS

Multimorbid patients had more than twice as many contacts per year with physicians than those without multimorbidity (36 vs. 16). These contact frequencies were associated with visits to 5.7 different physicians per year in case of multimorbidity vs. 3.5 when multimorbidity was not present. The number of contacts and of physicians contacted increased steadily with the number of chronic conditions. The number of contacts varied between 35 and 54 per year and the number of contacted physicians varied between 5 to 7, depending on the presence of individual chronic diseases and/or their triadic combinations. The influence of gender or age on utilization was small and clinically almost irrelevant. The most important factor influencing physician contact was the presence of nursing dependency due to disability.

CONCLUSION

In absolute terms, we found a very high rate of utilization of ambulatory medical care by the elderly in Germany, when multimorbidity and especially nursing dependency were present. The extent of utilization by the elderly was related both to the number of chronic conditions and to the individual multimorbidity patterns, but not to gender and almost not to age.

Physician visits and colorectal cancer testing among Medicare enrollees in North Carolina and South Carolina, 2005

INTRODUCTION

Many Medicare enrollees do not receive colorectal cancer tests at recommended intervals despite having Medicare screening coverage. Little is known about the physician visits of Medicare enrollees who are untested. Our study objective was to evaluate physician visits of enrollees who lack appropriate testing to identify opportunities to increase colorectal cancer testing.

METHODS

We used North Carolina and South Carolina Medicare data to compare type and frequency of physician visits for Medicare enrollees with and without a colorectal cancer test in 2005. Type of physician visit was defined by the physician specialty as primary care, mixed specialty (more than 1 specialty, 1 of which was primary care), and nonprimary care. We used multivariate modeling to assess the influence of type and frequency of physician visits on colorectal cancer testing.

RESULTS

Approximately half (46.5%) of enrollees lacked appropriate colorectal cancer testing. Among the untested group, 19.8% had no physician visits in 2005. Enrollees with primary care visits were more likely to be tested than those without a primary care visit. Many enrollees who had primary care visits remained untested. Enrollees with visits to all physician types had a greater likelihood of having colorectal cancer testing.

CONCLUSION

We identified 3 categories of Medicare enrollees without appropriate colorectal cancer testing: those with no visits, those who see primary care physicians only, and those with multiple visits to physicians with primary and nonprimary care specialties. Different strategies are needed for each category to increase colorectal cancer testing in the Medicare population.

Progress of Ontario's Family Health Team model: a patient-centered medical home

Ontario's Family Health Team (FHT) model, implemented in 2005, may be North America's largest example of a patient-centered medical home. The model, based on multidisciplinary teams and an innovative incentive-based funding system, has been developed primarily from fee-for-service primary care practices. Nearly 2 million Ontarians are served by 170 FHTs. Preliminary observations suggest high satisfaction among patients, higher income and more gratification for family physicians, and trends for more medical students to select careers in family medicine. Popular demand is resulting in expansion to 200 FHTs. We describe the development, implementation, reimbursement plan, and current status of this multidisciplinary model, relating it to the principles of the patient-centered medical home. We also identify its potential to provide an understanding of many aspects of primary care.

Dropping the baton: specialty referrals in the United States

CONTEXT

In the United States, more than a third of patients are referred to a specialist each year, and specialist visits constitute more than half of outpatient visits. Despite the frequency of referrals and the importance of the specialty-referral process, the process itself has been a long-standing source of frustration among both primary care physicians (PCPs) and specialists. These frustrations, along with a desire to lower costs, have led to numerous strategies to improve the specialty-referral process, such as using gatekeepers and referral guidelines.

METHODS

This article reviews the literature on the specialty-referral process in order to better understand what is known about current problems with the referral process and what solutions have been proposed. The article first provides a conceptual framework and then reviews prior literature on the referral decision, care coordination including information transfer, and access to specialty care.

FINDINGS

PCPs vary in their threshold for referring a patient, which results in both the underuse and the overuse of specialists. Many referrals do not include a transfer of information, either to or from the specialist; and when they do, it often contains insufficient data for medical decision making. Care across the primary-specialty interface is poorly integrated; PCPs often do not know whether a patient actually went to the specialist, or what the specialist recommended. PCPs and specialists also frequently disagree on the specialist's role during the referral episode (e.g., single consultation or continuing co-management).

CONCLUSIONS

There are breakdowns and inefficiencies in all components of the specialty-referral process. Despite many promising mechanisms to improve the referral process, rigorous evaluations of these improvements are needed.

The political economy of U.S. primary care

Compelling evidence suggests that the United States lags behind other developed nations in the health of its population and the performance of its health care system, partly as a result of a decades-long decline in primary care. This paper outlines the political, economic, policy, and institutional factors behind this decline. A large-scale, multifaceted effort--a new Charter for Primary Care--is required to overcome these forces. There are grounds for optimism for the success of this effort, which is essential to achieving health outcomes and health system performance comparable to those of other industrialized nations.

Specialty care and the patient-centered medical home

BACKGROUND

The medical home's success depends, in part, on the degree to which primary care physicians (PCPs) and specialists collaborate to create "medical neighborhoods" based on collective accountability. Such collaboration may require a new equilibrium in chronic disease care, with some of the routine follow-up currently provided by specialists reallocated to PCPs and their medical home teams.

OBJECTIVES

To measure the care delivered by specialists for 7 chronic conditions, and to estimate the implications associated with reallocating half among the PCP workforce.

RESEARCH DESIGN

Cross-sectional.

SUBJECTS

Physicians from the 2007 National Ambulatory Medical Care Survey.

MEASURES

We identified adult ambulatory visits for chronic obstructive pulmonary disease/asthma, low back pain, diabetes mellitus, coronary artery disease/congestive heart failure, chronic kidney disease, and depression. We calculated the time spent by specialists in direct and indirect care for established patients with these conditions. We summed individual physician estimates across specialists and converted the total into annual work weeks. After reducing this figure by half, we divided by the number of active PCPs.

RESULTS

Most specialty visits (76.8%; 95% confidence interval [CI]: 73.6%-79.7%) were made by established patients. Specialists spent 552,844 (95% CI: 454,660-651,029) and 108,113 (95% CI: 86,103-130,122) cumulative work weeks providing direct and indirect follow-up care, respectively. Reallocating half of this care would generate 3.2 (95% CI: 2.6-3.8) additional work weeks for each PCP.

CONCLUSIONS

The cumulative time spent by specialists in routine chronic disease follow-up is nontrivial. Reallocation of this care to PCP-directed medical homes may require multidimensional efforts to expand the primary care workforce.

Job satisfaction of primary care team members and quality of care

In recent years, hospitals and payers have increased their efforts to improve the quality of patient care by encouraging provider adherence to evidence-based practices. Although the individual provider is certainly essential in the delivery of appropriate care, a team perspective is important when examining variation in quality. In the present study, the authors modeled the relationship between a measure of aggregate job satisfaction for members of primary care teams and objective measures of quality based on process indicators and intermediate outcomes. Multilevel analyses indicated that aggregate job satisfaction ratings were associated with higher values on both types of quality measures. Team-level job satisfaction ratings are a potentially important marker for the effectiveness of primary care teams in managing patient care.