Urologists and the patient centered medical home

Establishing a medical home for patients with inflammatory bowel diseases: a qualitative study

The Patient-Centered Medical Home model has gained popularity in primary care to provide early effective care to patients with chronic conditions. Prior research on specialty medical homes has been cross-sectional and focused on patient outcomes. The objective of this longitudinal qualitative study was to identify best practices in establishing a specialty medical home in Inflammatory Bowel Diseases (IBD Home). The multimethod study included direct observations of multidisciplinary team meetings (30 hours over one year) and in-depth interviews with individual team members (N=11) and referring physicians (N=6) around their participation in the IBD home. All interviews were professionally transcribed verbatim. Two researchers coded transcripts for themes using NVivo software. Weekly team meetings (N=9±3) included behavioral health providers, nurse practitioners, nurses, dietitians, a clinical pharmacist, and clinical coordinators. Physicians referred patients with psychosocial comorbidities to the IBD home. Initially the team enrolled all referred patients. Later, they developed exclusion criteria and a patient complexity score to manage the volume. Some providers reported increase in their workload (social work, nutrition) while others’ workload was unaffected (gastroenterology, nursing). No physicians attended team meetings regularly. Regular in-person meetings helped to strengthen the team. Involving physicians as consultants on an ad hoc basis without regular meeting attendance empowered other team members to take ownership of the IBD Home.

Differences in the Treatment of Benign Prostatic Hyperplasia: Comparing the Primary Care Physician and the Urologist

INTRODUCTION

Benign prostatic hyperplasia is a prevalent chronic condition with expenditures exceeding $1 billion each year. Little is known about management of patients by primary care physicians compared to urologists. We assessed changes in management after medication initiation in these two settings.

METHODS

From the Chronic Condition Warehouse 5% sample of Medicare beneficiaries linked to Medicare Part D data, we defined a cohort of men, 66 to 90 years old, with initial prescriptions for alpha-blocker, 5-alpha reductase inhibitor (5-ARI), or both. We assessed the initial change in therapy for up to four years after medication initiation: add a medication, switch medication, stop medication, or have surgery/retention. We estimated the cumulative incidence functions from competing risks data, and tested equality across groups (primary care physician vs. urologist).

RESULTS

5714 men started medication with a primary care physician, 1970 with a urologist. The most common change in treatment after medication initiation across all groups was medication discontinuation (55% alpha blocker; 46% 5-ARI; 30% combination therapy cumulative incidence at 3 years). Patients who started with primary care physicians were more likely to discontinue BPH-related medications, than patients with urologists (HR 1.19; 95% CI 1.09 - 1.29). The majority of patients who stopped alpha blocker therapy did not have further BPH therapy.

CONCLUSIONS

Men given combination therapy are most likely to have continued medication use. Surgical therapy and retention are relatively rare events. Patients who initiate care with urologists are more likely to continue medical therapy than patients with care initiated by primary care providers.