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Shiau C, Kim DY, Young PA, Baker A, Bae GH. Trends in dermatologic procedures performed by dermatologists and advanced practice clinicians among Medicare beneficiaries from 2012 to 2020. J Am Acad Dermatol 2024; 90:1054-1057. [PMID: 38242175 DOI: 10.1016/j.jaad.2023.12.061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 11/22/2023] [Accepted: 12/30/2023] [Indexed: 01/21/2024]
Affiliation(s)
| | | | - Peter A Young
- Department of Dermatology, Stanford University School of Medicine, Redwood City, California; Department of Dermatology, The Permanente Medical Group, Sacramento, California
| | | | - Gordon H Bae
- Department of Dermatology, Stanford University School of Medicine, Redwood City, California.
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Abstract
INTRODUCTION We examined the coronavirus disease 2019 (COVID-19) pandemic impact on weekly trends in the billing of virtual and in-person physician visits in Ontario, Canada. METHODS In this retrospective cohort study, physician billing records from Ontario were aggregated on a weekly basis for in-person and virtual visits from 3 January 2016 to 27 March 2021. For each type of visit, a segmented negative binomial regression analysis was performed to estimate the weekly pre-pandemic trend in billing volume per thousand adults (3 January 2016 to 14 March 2020), the immediate change in mean volume at the start of the pandemic, and additional change in weekly volume in the pandemic era (15 March 2020 to 27 March 2021). RESULTS Before the start of the pandemic, the weekly volume of virtual visits per thousand adults was low with a 0.5% increase per week (rate ratio [RR]: 1.0053, 95% confidence interval [CI]: 1.0050-1.0056). A dramatic 65% reduction in in-person visits (RR: 0.35, 95% CI: 0.32-0.39) occurred at the start of the pandemic while virtual visits grew by 21-fold (RR: 21.3, 95% CI: 19.6-23.0). In the pandemic era, in-person visits rose by 1.4% per week (RR: 1.014, 95% CI: 1.011-1.017) but no change was observed for virtual visits (p-value = 0.31). Overall, we noted a 57.6% increase in total weekly physician visits volume after the start of the pandemic. DISCUSSION These results are meaningful for virtual care reimbursement models. Future study needs to assess the quality of care and whether the increase in virtual care volume is cost-effective to society.
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Affiliation(s)
- Rui Fu
- ICES, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Department of Otolaryngology – Head and Neck Surgery, Michael Garron Hospital and Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Rinku Sutradhar
- ICES, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Qing Li
- ICES, Toronto, Ontario, Canada
| | - Antoine Eskander
- ICES, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Department of Otolaryngology – Head and Neck Surgery, Michael Garron Hospital and Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
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Abstract
We stand at a critical juncture in the delivery of health care for hypertension. Blood pressure control rates have stagnated, and traditional health care is failing. Fortunately, hypertension is exceptionally well-suited to remote management, and innovative digital solutions are proliferating. Early strategies arose with the spread of digital medicine, long before the COVID-19 pandemic forced lasting changes to the way medicine is practiced. Highlighting one contemporary example, this review explores salient features of remote management hypertensive programs, including: an automated algorithm to guide clinical decisions, home (as opposed to office) blood pressure measurements, an interdisciplinary care team, and robust information technology and analytics. Dozens of emerging hypertension management solutions are contributing to a highly fragmented and competitive landscape. Beyond viability, profit and scalability are critical. We explore the challenges impeding large-scale acceptance of these programs and conclude with a hopeful look to the future when remote hypertension care will have dramatic impact on global cardiovascular health.
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Affiliation(s)
- Simin Gharib Lee
- Division of Cardiology, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
| | - Naomi D.L. Fisher
- Division of Endocrinology, Diabetes and Hypertension, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
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Lovis C, Fraser M, Tuna M, Bruntz C, Dahrouge S. The Impact of an Electronic Portal on Patient Encounters in Primary Care: Interrupted Time-Series Analysis. JMIR Med Inform 2023; 11:e43567. [PMID: 36745495 PMCID: PMC9941901 DOI: 10.2196/43567] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 12/15/2022] [Accepted: 01/08/2023] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Electronic patient portals are online applications that allow patients access to their own health information, a form of asynchronous virtual care. The long-term impact of portals on the use of traditional primary care services is unclear, but it is an important question at this juncture, when portals are being incorporated into many primary care practices. OBJECTIVE We sought to investigate how an electronic patient portal affected the use of traditional, synchronous primary care services over a much longer time period than any existing studies and to assess the impact of portal messaging on clinicians' workload. METHODS We conducted a propensity-score-matched, open-cohort, interrupted time-series evaluation of a primary care portal from its implementation in 2010. We extracted information from the electronic medical record regarding age, sex, education, income, family health team enrollment, diagnoses at index date, and number of medications prescribed in the previous year. We also extracted the annual number of encounters for up to 8 years before and after the index date and provider time spent on secure messaging through the portal. RESULTS A total of 7247 eligible portal patients and 7647 eligible potential controls were identified, with 3696 patients matched one to one. We found that portal registration was associated with an increase in the number of certain traditional encounters over the time period surrounding portal registration. Following the index year, there was a significant jump in annual number of visits to physicians in the portal arm (0.42 more visits/year vs control, P<.001) but not for visits to nurse practitioners and physician assistants. The annual number of calls to the practice triage nurses also showed a greater increase in the portal arm compared to the control arm after the index year (an additional 0.10 calls, P=.006). The average provider time spent on portal-related work was 5.7 minutes per patient per year. CONCLUSIONS We found that portal registration was associated with a subsequent increase in the number of some traditional encounters and an increase in clerical workload for providers. Portals have enormous potential to truly engage patients as partners in their own health care, but their impact on use of traditional health care services and clerical burden must also be considered when they are incorporated into primary care.
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Affiliation(s)
| | - Mark Fraser
- West Carleton Family Health Team, Carp, ON, Canada
| | - Meltem Tuna
- ICES, Ottawa, ON, Canada.,Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | | | - Simone Dahrouge
- Department of Family Medicine, University of Ottawa, Ottawa, ON, Canada.,Bruyère Research Institute, Ottawa, ON, Canada
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Karande S, Chong GTF, Megally H, Parmar D, Taylor GW, Obadan‐Udoh EM, Agaku IT. Changes in dental and medical visits before and during the COVID-19 pandemic among U.S. children aged 1-17 years. Community Dent Oral Epidemiol 2022; 51:483-493. [PMID: 36326121 PMCID: PMC9877772 DOI: 10.1111/cdoe.12806] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 10/14/2022] [Accepted: 10/17/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVES The COVID-19 pandemic has tremendously impacted the U.S. healthcare system, but no study has examined the impact of the pandemic on utilization of dental care among U.S. children. Changes in past-year dental versus medical visits and perceived unmet health needs between 2019 and 2020 among U.S. children aged 1-17 years were examined. METHODS National and state representative, cross-sectional data from the National Survey of Children's Health conducted during June 2019-January 2020 (i.e. pre-pandemic, n = 28 500) and July 2020-January 2021 (i.e. intra-pandemic, n = 41 380) were analysed. Any past-year visit and perceived unmet needs (i.e. delay or inability to receive needed care) were reported by the parent proxy. Weighted prevalence estimates were compared using two-tailed chi-squared tests at p < .05. Poisson regression analyses were used to explore the relationship between having dental and/or medical unmet needs during the pandemic and indicators of poor health and social wellbeing. RESULTS Between 2019 and 2020, a significantly reduced prevalence of past-year medical (87.2%-81.3%) and dental visits (82.6%-78.2%) among U.S. children aged 1-17 years (all p < .05) were observed. Correspondingly, perceived unmet needs increased by half for dental care (from 2.9% in 2019 to 4.4% in 2020) and almost one-third for medical care (from 3.2% to 4.2% in 2020). Subgroups with the highest prevalence of unmet dental need included those with low socio-economic status, living with their grandparents, uninsured and living with a smoker. CONCLUSIONS Unmet health needs increased in general but increased more for dental than for medical care among U.S. children aged 1-17 years. Enhanced and sustained efforts will be needed to deliver targeted services towards disadvantaged segments of the population to narrow existing disparities.
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Affiliation(s)
- Sharvari Karande
- Division of Oral Epidemiology and Dental Public HealthUniversity of California San FranciscoSan FranciscoCaliforniaUSA
| | - Gabriel Tse Feng Chong
- Division of Oral Epidemiology and Dental Public HealthUniversity of California San FranciscoSan FranciscoCaliforniaUSA
| | - Hayam Megally
- Division of Oral Epidemiology and Dental Public HealthUniversity of California San FranciscoSan FranciscoCaliforniaUSA
| | - Digvijaysinh Parmar
- Division of Oral Epidemiology and Dental Public HealthUniversity of California San FranciscoSan FranciscoCaliforniaUSA
| | - George W. Taylor
- Division of Oral Epidemiology and Dental Public HealthUniversity of California San FranciscoSan FranciscoCaliforniaUSA
| | - Enihomo Mary Obadan‐Udoh
- Division of Oral Epidemiology and Dental Public HealthUniversity of California San FranciscoSan FranciscoCaliforniaUSA
| | - Israel Terungwa Agaku
- Division of Oral Epidemiology and Dental Public HealthUniversity of California San FranciscoSan FranciscoCaliforniaUSA,Department of Oral Health Policy and EpidemiologyHarvard School of Dental MedicineBostonMassachusettsUSA
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6
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Elias ED, Silvester JA, Bernstein CN, Rigaux LN, Graff LA, Duerksen DR. Patient Perspectives on the Long-term Management of Celiac Disease. J Clin Gastroenterol 2022; 56:869-874. [PMID: 34334763 PMCID: PMC8800942 DOI: 10.1097/mcg.0000000000001584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Accepted: 06/06/2021] [Indexed: 01/03/2023]
Abstract
GOAL The aim of this study was to survey adults with celiac disease (CD) on the utility of specific aspects of follow-up and on information needs. BACKGROUND Currently, the treatment for CD is strict gluten avoidance. Although this places the onus on the patient for disease management, patient perspectives on CD care have not been formally assessed. STUDY The Manitoba Celiac Disease Cohort prospectively enrolled adults newly diagnosed with CD using serology and histology. At the 24-month study visits, participants rated the utility of aspects of CD care on a 5-point scale anchored by "not at all useful" and "very useful" and the helpfulness of information on CD-related topics on a 6-point scale anchored by "not at all helpful" and "very helpful." RESULTS The online survey was completed by 149 of 211 cohort members [median age 40 (interquartile range 30 to 56) y; 68% female]. Adherence to a gluten-free diet was good. Most participants (87%) responded that they should be seen regularly for medical follow-up of CD, preferably every 6 (26%) or 12 months (48%). Blood tests were the most highly rated care component (rated scored ≥4/5 by 78% of respondents), followed by the opportunity to ask about vitamins and supplements (50%), symptom review (47%), and information on CD research (44%). Diet review was not considered helpful. CONCLUSIONS Two years after diagnosis, most individuals with CD find regular specialist follow-up helpful, particularly for biochemical assessment of disease activity and its complications. Furthermore, information on research and long-term complications of CD is also valued.
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Affiliation(s)
- Evan D Elias
- Department of Internal Medicine, Section of Gastroenterology
| | - Jocelyn A Silvester
- Harvard Celiac Research Program, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | | | - Lisa N Rigaux
- St. Boniface Hospital Research Centre, Winnipeg, MB, Canada
| | - Lesley A Graff
- Department of Clinical Health Psychology, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba
| | - Donald R Duerksen
- Department of Internal Medicine, Section of Gastroenterology
- St. Boniface Hospital Research Centre, Winnipeg, MB, Canada
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7
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Plug I, van Dulmen S, Stommel W, Olde Hartman TC, Das E. Physicians' and Patients' Interruptions in Clinical Practice: A Quantitative Analysis. Ann Fam Med 2022; 20:423-429. [PMID: 36228066 PMCID: PMC9512556 DOI: 10.1370/afm.2846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 04/15/2022] [Accepted: 05/04/2022] [Indexed: 11/09/2022] Open
Abstract
PURPOSE Physicians' interruptions have long been considered intrusive, masculine actions that inhibit patient participation, but a systematic analysis of interruptions in clinical interaction is lacking. This study aimed to examine when and how primary care physicians and patients interrupt each other during consultations. METHODS We coded and quantitatively analyzed interruption type (cooperative vs intrusive) in 84 natural interactions between 17 primary care physicians and 84 patients with common somatic symptoms. Data were analyzed using a mixed-effects logistic regression model, with role, gender, and consultation phase as predictors. RESULTS Of the 2,405 interruptions observed, 82.9% were cooperative. Among physicians, men were more likely to make an intrusive interruption than women (β = 0.43; SE, 0.21; odds ratio [OR] = 1.54; 95% CI, 1.03-2.31), whereas among patients, men were less likely to make an intrusive interruption than women (β = -0.35; SE, 0.17; OR = 0.70; 95% CI, 0.50-0.98). Patients' interruptions were more likely to be intrusive than physicians' interruptions in the phase of problem presentation (β = 0.71; SE, 0.23; OR = 2.03; 95% CI, 1.30-3.20), but not in the phase of diagnosis and/or treatment plan discussion (β = -0.17; SE, 0.15; OR = 0.85; 95% CI, 0.63-1.15). CONCLUSIONS Most interruptions in clinical interaction are cooperative and may enhance the interaction. The nature of physicians' and patients' interruptions is the result of an interplay between role, gender, and consultation phase.
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Affiliation(s)
- Ilona Plug
- Centre for Language Studies, Radboud University, Nijmegen, The Netherlands
| | - Sandra van Dulmen
- Radboud University Medical Center, Radboud Institute for Health Sciences, Department of Primary and Community Care, Nijmegen, The Netherlands.,Nivel (Netherlands Institute for Health Services Research), Utrecht, The Netherlands.,Faculty of Caring Science, Work Life and Social Welfare, University of Borås, Borås, Sweden
| | - Wyke Stommel
- Centre for Language Studies, Radboud University, Nijmegen, The Netherlands
| | - Tim C Olde Hartman
- Radboud University Medical Center, Radboud Institute for Health Sciences, Department of Primary and Community Care, Nijmegen, The Netherlands
| | - Enny Das
- Centre for Language Studies, Radboud University, Nijmegen, The Netherlands
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Ralston JD, Yu O, Penfold RB, Gundersen G, Ramaprasan A, Schartz EM. Changes in Clinician Attitudes Toward Sharing Visit Notes: Surveys Pre-and Post-Implementation. J Gen Intern Med 2021; 36:3330-3336. [PMID: 33886028 PMCID: PMC8061150 DOI: 10.1007/s11606-021-06729-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 03/16/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Clinician perceptions before and after inviting patients to read office notes (open notes) are unknown. OBJECTIVE To describe changes in clinicians' attitudes about sharing notes with patients. DESIGN, PARTICIPANTS, AND MAIN MEASURE Survey of outpatient primary and specialty care clinicians who were from a large group practice and had one or more patients who accessed notes. The main outcome was percent change (before vs. after implementation) in clinician perception that online visit notes are beneficial overall. KEY RESULTS Of the 563 invited clinicians, 400 (71%) took the baseline survey; 295 were eligible for a follow-up survey with 192 (65%) responding (119 primary care, 47 medical specialties, 26 surgical specialties). Before implementation, 29% agreed or somewhat agreed that visit notes online are beneficial overall, increasing to 71% following implementation (p<0.001); 44% switched beliefs from bad to good idea; and 2% reported the opposite change (p<0.001). This post-implementation change was observed in all clinician categories. Compared to pre-implementation, fewer clinicians had concerns about office visits taking longer (47% pre vs. 15% post) or requiring more time for questions (71% vs. 16%), or producing notes (57% vs. 28%). Before and after implementation, most clinicians reported being less candid in documentation (65% vs. 52%) and that patients would have more control of their care (72% vs. 78%) and worry more (72% vs. 65%). CONCLUSIONS Following implementation, more primary and specialty care clinicians agreed that sharing notes with patients online was beneficial overall. Fewer had concerns about more time needed for office visits or documentation. Most thought patients would worry more and reported being less candid in documentation.
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Affiliation(s)
- James D Ralston
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA.
| | - Onchee Yu
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | - Robert B Penfold
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | | | - Arvind Ramaprasan
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | - Ellen M Schartz
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
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Beach MC, Park J, Han D, Evans C, Moore RD, Saha S. Clinician Response to Patient Emotion: Impact on Subsequent Communication and Visit Length. Ann Fam Med 2021; 19:515-520. [PMID: 34750126 PMCID: PMC8575526 DOI: 10.1370/afm.2740] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 03/15/2021] [Accepted: 04/13/2021] [Indexed: 11/09/2022] Open
Abstract
PURPOSE It is widely cited-based on limited evidence-that attending to a patient's emotions results in shorter visits because patients are less likely to repeat themselves if they feel understood. We evaluated the association of clinician responses to patient emotions with subsequent communication and visit length. METHODS We audio-recorded 41 clinicians with 342 unique patients and used the Verona Coding Definitions of Emotional Sequences (VR-CoDES) to time stamp patient emotional expressions and categorize clinician responses. We used random-intercept multilevel-regression models to evaluate the associations of clinician responses with timing of the expressed emotion, patient repetition, and subsequent length of visit. RESULTS The mean visit length was 30.4 minutes, with 1,028 emotional expressions total. The majority of clinician responses provided space for the patient to elaborate on the emotion (81%) and were nonexplicit (56%). As each minute passed, clinicians had lower odds of providing space (odds ratio [OR] = 0.96; 95% CI, 0.95-0.98) and higher odds of being explicit (OR = 1.02; 95% CI, 1.00-1.03). Emotions were more likely to be repeated when clinicians provided space (OR = 2.33; 95% CI, 1.66-3.27), and less likely to be repeated when clinicians were explicit (OR = 0.61; 95% CI, 0.47-0.80). Visits were shorter (β = -0.98 minutes; 95% CI, -2.19 to 0.23) when clinicians' responses explicitly focused on patient affect. CONCLUSION If saving time is a goal, clinicians should consider responses that explicitly address a patient's emotion. Arguments for providing space for patients to discuss emotional issues should focus on other benefits, including patients' well-being.
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Affiliation(s)
- Mary Catherine Beach
- Division of General Internal Medicine, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland .,Berman Institute of Bioethics, Johns Hopkins University, Baltimore, Maryland.,Department of Health, Behavior & Society, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland.,Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins University, Baltimore, Maryland
| | - Jenny Park
- Division of General Internal Medicine, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Dingfen Han
- Division of General Internal Medicine, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Christopher Evans
- Division of General Internal Medicine and Geriatrics, Oregon Health and Science University, Portland, Oregon
| | - Richard D Moore
- Division of General Internal Medicine, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Somnath Saha
- Division of General Internal Medicine and Geriatrics, Oregon Health and Science University, Portland, Oregon.,Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, Oregon
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Sundar KR. Virtual Care: Choosing the Right Tool, at the Right Time. Ann Fam Med 2021; 19:365-367. [PMID: 34264842 PMCID: PMC8282302 DOI: 10.1370/afm.2693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 08/21/2020] [Accepted: 09/01/2020] [Indexed: 11/09/2022] Open
Abstract
When the immediate threat of COVID-19 subsides, the future of health care will involve more virtual care. Before the pandemic, patient choice rather than clinician guidance determined which medium (telephone visits, video visits, electronic messaging) was used to receive care. Two media synchronicity theory principles-conveyance and convergence-can create a framework for determining how to choose the right medium of care for the patient. The author describes how it changed their practice and decision making with a patient story that required the use of multiple virtual care options.
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Salisbury C, Lay-Flurrie S, Bankhead CR, Fuller A, Murphy M, Caddick B, Ordóñez-Mena JM, Holt T, Nicholson BD, Perera R, Hobbs FR. Measuring the complexity of general practice consultations: a Delphi and cross-sectional study in English primary care. Br J Gen Pract 2021; 71:e423-31. [PMID: 33824162 DOI: 10.3399/BJGP.2020.0486] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Accepted: 11/13/2020] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND The complexity of general practice consultations may be increasing and varies in different settings. A measure of complexity is required to test these hypotheses. AIM To develop a valid measure of general practice consultation complexity applicable to routine medical records. DESIGN AND SETTING Delphi study to select potential indicators of complexity followed by a cross-sectional study in English general practices to develop and validate a complexity measure. METHOD The online Delphi study over two rounds identified potential indicators of consultation complexity. The cross-sectional study used an age-sex stratified random sample of patients and general practice face-to-face consultations from 2013/2014 in the Clinical Practice Research Datalink. The authors explored independent relationships between each indicator and consultation duration using mixed-effects regression models, and revalidated findings using data from 2017/2018. The proportion of complex consultations in different age-sex groups was assessed. RESULTS A total of 32 GPs participated in the Delphi study. The Delphi panel endorsed 34 of 45 possible complexity indicators after two rounds. After excluding factors because of low prevalence or confounding, 17 indicators were retained in the cross-sectional study. The study used data from 173 130 patients and 725 616 face-to-face GP consultations. On defining complexity as the presence of any of these 17 factors, 308 370 consultations (42.5%) were found to be complex. Mean duration of complex consultations was 10.49 minutes, compared to 9.64 minutes for non-complex consultations. The proportion of complex consultations was similar in males and females but increased with age. CONCLUSION The present consultation complexity measure has face and construct validity. It may be useful for research, management and policy, and for informing decisions about the range of resources needed in different practices.
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Johansen ME, Yun JDY. Trends in Total and Out-of-Pocket Expenditures for Visits to Primary Care Physicians, by Insurance Type, 2002-2017. Ann Fam Med 2020; 18:430-437. [PMID: 32928759 PMCID: PMC7489978 DOI: 10.1370/afm.2566] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Revised: 03/04/2020] [Accepted: 03/05/2020] [Indexed: 11/09/2022] Open
Abstract
PURPOSE Total and out-of-pocket visit expenditures for primary care physician visits may affect how primary care is delivered. We determined trends in these expenditures for visits to US primary care physicians. METHODS Using the 2002-2017 Medical Expenditure Panel Survey, we ascertained changes in total and out-of-pocket visit expenditures for primary care visits for Medicare, Medicaid, and private insurance. We calculated mean values for each insurer using a generalized linear model and a 2-part model, respectively. RESULTS Analyses were based on 750,837 primary care visits during 2002-2017. Over time, the proportion of primary care visits associated with private insurance or no insurance decreased, while Medicare- or Medicaid-associated visits increased. The proportion of visits with $0 out-of-pocket expenditure increased, primarily from an increase in $0 private insurance visits. Total expenditure per visit increased for private insurance and Medicare visits, but did not notably change for Medicaid visits. Out-of-pocket expenditures rose primarily from increases in private insurance visits with higher expenditures of this type. Medicare and Medicaid had minimal change in out-of-pocket expenditure per visit. CONCLUSIONS Between 2002 and 2017, mean total expenditures and out-of-pocket expenditures increased for primary care visits, but at notably lower rates than those previously documented for emergency department visits. A rise in total expenditure per visit was identified for private insurance and Medicare, but not for Medicaid. Out-of-pocket expenditures increased marginally related to changes in out-of-pocket expenditures for private insurance visits. We would expect increasing difficulty with primary care physician access, particularly for Medicaid patients, if the current trends continue.
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Affiliation(s)
- Michael E Johansen
- Grant Family Medicine, OhioHealth, Columbus, Ohio .,Heritage College of Osteopathic Medicine at Ohio University, Dublin, Ohio
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13
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Shim JJ, Kim GA, Oh CH, Kim JW, Myung J, Kim BH, Oh IH. Reduced liver cancer mortality with regular clinic follow-up among patients with chronic hepatitis B: A nationwide cohort study. Cancer Med 2020; 9:7781-7791. [PMID: 32857923 PMCID: PMC7571840 DOI: 10.1002/cam4.3421] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 08/05/2020] [Accepted: 08/07/2020] [Indexed: 01/15/2023] Open
Abstract
Background Regular clinic follow‐up is a prerequisite for optimal antiviral therapy and surveillance of hepatocellular carcinoma in patients with chronic hepatitis B (CHB). However, adherence to regular follow‐up stays low in practice. This study investigated whether regular follow‐up is associated with decreased liver cancer mortality in CHB patients. Methods A nationwide population‐based historical cohort study was conducted using customized data from the National Health Insurance Service of Korea. The number of hospital visits every 3‐month interval was counted for 2 years from the date of CHB diagnosis. Patients were classified into three follow‐up groups: regular (four to eight visits), irregular (one to three visits), and no follow‐up. The risk of liver cancer mortality was compared among the groups using Cox proportional hazard regression analysis. Results Of the 414 074 CHB patients, 22.9% had regular follow‐up. In multivariable analysis, regular follow‐up was independently associated with decreased risk of liver cancer mortality compared to no follow‐up (hazard ratio [HR], 0.56; 95% confidence interval [CI], 0.50‐0.63, P < .001). Regular follow‐up was also associated with the lowest risk of all‐cause mortality (HR, 0.60; 95% CI, 0.57‐0.63, P < .001). Patients with regular follow‐up received more curative treatment (23.1% vs 15.1%, P < .001). Patients were less motivated when they were female, >60 years, of low socioeconomic status, disabled, lived in a rural area, had a higher comorbidity rate, or did not have cirrhosis. Conclusions Regular follow‐up at least every 3‐6 months is significantly associated with reduced liver cancer mortality in patients with CHB.
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Affiliation(s)
- Jae-Jun Shim
- Department of Internal Medicine, Kyung Hee University School of Medicine, Seoul, Korea
| | - Gi-Ae Kim
- Department of Internal Medicine, Kyung Hee University School of Medicine, Seoul, Korea
| | - Chi Hyuk Oh
- Department of Internal Medicine, Kyung Hee University School of Medicine, Seoul, Korea
| | - Jung Wook Kim
- Department of Internal Medicine, Kyung Hee University School of Medicine, Seoul, Korea
| | - Jisun Myung
- Department of Preventive Medicine, School of Medicine, Kyung Hee University, Seoul, Korea
| | - Byung-Ho Kim
- Department of Internal Medicine, Kyung Hee University School of Medicine, Seoul, Korea
| | - In-Hwan Oh
- Department of Preventive Medicine, School of Medicine, Kyung Hee University, Seoul, Korea
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Cuspidi C, Facchetti R, Dell'Oro R, Quarti-Trevano F, Tadic M, Mancia G, Grassi G. Office and Out-of-Office Blood Pressure Changes Over a Quarter of Century: Findings From the PAMELA Study. Hypertension 2020; 76:759-765. [PMID: 32755470 DOI: 10.1161/hypertensionaha.120.15434] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Findings regarding long-terms variations in blood pressure (BP) taken in different setting (ie, office, home, and ambulatory BP) in the community are scanty. We sought to assess this issue in members of the general population enrolled in the PAMELA (Pressioni Monitorate E Loro Associazioni) study. The study included 562 participants who attended the second and third survey of the PAMELA study performed after 10 and 25 years from the initial evaluation. Data collection included medical history, anthropometric parameters, office, home, ambulatory BP, and standard blood examinations. Office, home, and 24-hour systolic BP over the 25-year interval between the first and third survey increased in a parallel way (ie, 12%, 10%, and 15.5%). The increments in office, home, and 24-hour diastolic BP were lower than the systolic BP ones (ie, 3.3%, 5.6%, and 6.1%). Thus, the combined changes in systolic BP and diastolic BP from the first to the third data collection resulted in a marked increase in pulse pressure (ie, 29%, 19%, and 30%). The prevalence of hypertension assessed at office visits and out-of-office either by self-BP measurements at home and ambulatory blood pressure monitoring increased ≈3 to 4× (3.1 office, 3.3 home, 3.9 ABPM, respectively). This trend was associated with adiposity indexes and worsening of the glucose profile. This community-based longitudinal study suggests that the progressive and marked increase in hypertension with age, consistently documented with different BP measurement methods, represents an epochal challenge for the prevention of cardiovascular diseases, due to the rapid growth the elderly population worldwide.
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Affiliation(s)
- Cesare Cuspidi
- From the Department of Medicine and Surgery, University of Milano-Bicocca, Milano, Italy (C.C., R.F., R.D., F.Q.-T., G.G.).,Istituto Auxologico Italiano IRCCS, Milano, Italy (C.C.)
| | - Rita Facchetti
- From the Department of Medicine and Surgery, University of Milano-Bicocca, Milano, Italy (C.C., R.F., R.D., F.Q.-T., G.G.)
| | - Raffaella Dell'Oro
- From the Department of Medicine and Surgery, University of Milano-Bicocca, Milano, Italy (C.C., R.F., R.D., F.Q.-T., G.G.)
| | - Fosca Quarti-Trevano
- From the Department of Medicine and Surgery, University of Milano-Bicocca, Milano, Italy (C.C., R.F., R.D., F.Q.-T., G.G.)
| | - Marijana Tadic
- Department of Cardiology, University Hospital "Dr. Dragisa Misovic - Dedinje", Serbia (M.T.)
| | - Giuseppe Mancia
- University of Milano-Bicocca and Policlinico di Monza, Italy (G.M.)
| | - Guido Grassi
- From the Department of Medicine and Surgery, University of Milano-Bicocca, Milano, Italy (C.C., R.F., R.D., F.Q.-T., G.G.)
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15
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Darlison Shepherd PR, Krejany CJ, Jiwa M. How does the duration of consults vary for upper respiratory tract infections in general practice where an antibiotic has been prescribed? Fam Pract 2020; 37:213-218. [PMID: 31536617 DOI: 10.1093/fampra/cmz058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND There is limited data on the duration of consults resulting in the prescription of antibiotics for upper respiratory tract infections (URTIs) in general practice. OBJECTIVE To explore how demographic factors influence consult duration where antibiotics have been prescribed for URTI in Australian general practice. METHODS 2985 URTI-specific presentations were identified from a national study of patients who were prescribed an antibiotic after presenting to general practice between June and September 2017. Consult duration was analysed to assess for any variation in visit length based on demographic factors. RESULTS The overall median consult duration was 11.42 minutes [interquartile range (IQR) 7.95]. Longer consult duration was associated with areas of highest socio-economic advantage where patients living in postcodes of Index of Relative Socio-economic Advantage and Disadvantage (IRSAD) Quintile 5 (highest 20% on the IRSAD) had significantly longer consults [median 13.12 (IQR 8.01)] than all other quintiles (P < 0.001). Females [11.75 (IQR 8.13)] had significantly longer consults than males [10.87 (IQR 7.57); P < 0.001]. Clinics based in State C and State F had significantly shorter consults when compared with all other included states and territories (P < 0.001) and shorter consult duration was associated with visits on Sundays [median 8.18 (IQR 5.04)]. CONCLUSION There is evidence for the association of demographic and temporal factors with the duration of consultations for URTIs where an antibiotic has been prescribed. These factors warrant further research.
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Affiliation(s)
- Phoebe R Darlison Shepherd
- Melbourne Clinical School, School of Medicine Sydney, University of Notre Dame Australia, Werribee, Australia
| | - Catherine J Krejany
- Melbourne Clinical School, School of Medicine Sydney, University of Notre Dame Australia, Werribee, Australia
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16
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Affiliation(s)
- Mitchell Howard Rosner
- Department of Medicine, University of Virginia Health System, Charlottesville, Virginia; and
| | - Ronald J Falk
- Department of Medicine, University of North Carolina, Chapel Hill, Chapel Hill, North Carolina
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17
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Bayati M, Rashidian A. Descriptive Study of Economic Behavior of General Practitioners in Iran: Practice Income, Hours of Work, and Patient Visits. Int J Prev Med 2019; 10:217. [PMID: 31929864 PMCID: PMC6941379 DOI: 10.4103/ijpvm.ijpvm_408_17] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2017] [Accepted: 02/10/2018] [Indexed: 11/04/2022] Open
Abstract
Background Although there is a critical need for information on economic performance of Iranian general practitioners (GPs) in health policymaking, there is not any scientific evidence in this area. Therefore, in the present report, the characteristics of economic behaviors of Iranian GPs were described. Methods This was a cross-sectional study in 2015, in which the data were collected from 666 GPs. The variables including monthly gross income, hours of work, and patient visits were studied as the measures of economic behavior of GPs. Descriptive statistics, t-test, and Analysis of Variance were used for analyzing the data. The statistical analysis was performed by STATA12. Results The annual income of the GPs understudy was 26,000 US dollar (USD) (82,680 purchasing power parity [PPP]). The ratio of this value to gross domestic product per capita and minimum wage of Iran in 2015 was 4.8 and 9.2, respectively. On average, every GP in Iran has an income of 2188.1 USD (6958.16 PPP), works 142 h, and visits an average of 494 patients/month. The results showed that the economic behavior of Iranian GPs has a significant difference in terms of gender, age, marital status, practice experience, practice location, type of practice, being a family physicians, and working in different settings (P < 0.05). Conclusions The Iranian GPs understudy work less than their counterparts in other (compared) countries. The studied GPs had a higher income (adjusted by hours of work and countries' per capita income) than their counterparts in other (studied) countries. Moreover, there are inequalities between GPs in terms of income, the volume of services provided and the work hours.
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Affiliation(s)
- Mohsen Bayati
- Health Human Resources Research Center, School of Management and Information Sciences, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Arash Rashidian
- Department of Health Management and Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran.,Information, Evidence and Research, World Health Organization Regional Office for the Eastern Mediterranean, Cairo, Egypt
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18
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Bowers BL, Rowe JM, Fox LM, VanDeWege C, Billings S. A novel synchronized visit model as financial justification for clinic-embedded pharmacists. Am J Health Syst Pharm 2019; 76:2080-2086. [PMID: 31789350 DOI: 10.1093/ajhp/zxz244] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Brandi L Bowers
- School of Pharmacy, University of Missouri-Kansas City, Springfield, MO
| | - Jordan M Rowe
- School of Pharmacy, University of Missouri-Kansas City, Kansas City, MO
| | - Lauren M Fox
- Department of Pharmacy, University of Kansas Health System, Kansas City, KS
| | | | - Sarah Billings
- School of Pharmacy, University of Missouri-Kansas City, Springfield, MO
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Kyanko K, Hanley K, Zabar S, Joseph J, Bateman W, Schoenthaler A. Introducing Primary Care Telephone Visits: An Urban Safety-Net Community Clinic Experience. J Prim Care Community Health 2019; 9:2150132718792154. [PMID: 30079790 PMCID: PMC6080078 DOI: 10.1177/2150132718792154] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background: Telephone consultation is widely used in primary care
and can provide an effective and efficient alternative for the in-person visit.
Gouverneur Health, a safety-net primary care practice in New York City serving a
predominately immigrant population, evaluated the feasibility and physician and
patient acceptability of a telephone visit initiative in 2015.
Measures: Patient and physician surveys, and physician focus
groups. Results: Though only 85 of 270 scheduled telephone visits
(31%) were completed, 84% of patients reported being highly satisfied with their
telephone visit. Half of physicians opted to participate in the pilot. Among
participating physicians, all reported they were able to communicate adequately
and safely care for patients over the telephone. Conclusions:
Participating patients and physicians in a linguistically and culturally diverse
urban safety-net primary care clinic were highly satisfied with the use of
telephone visits, though completion of the visits was low. Lessons learned from
this implementation can be used to expand access and provision of high-quality
primary care to other vulnerable populations.
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Affiliation(s)
- Kelly Kyanko
- 1 New York University School of Medicine, New York, NY, USA
| | - Kathleen Hanley
- 1 New York University School of Medicine, New York, NY, USA.,2 Gouverneur Health, NYC Health + Hospitals, New York, NY, USA
| | - Sondra Zabar
- 1 New York University School of Medicine, New York, NY, USA.,2 Gouverneur Health, NYC Health + Hospitals, New York, NY, USA
| | | | - William Bateman
- 1 New York University School of Medicine, New York, NY, USA.,2 Gouverneur Health, NYC Health + Hospitals, New York, NY, USA
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Simon KC, Reams N, Beltran E, Wang C, Hadsell B, Maurer D, Hillman L, Tideman S, Garduno L, Meyers S, Frigerio R, Maraganore DM. Optimizing the electronic medical record to improve patient care and conduct quality improvement initiatives in a concussion specialty clinic. Brain Inj 2019; 34:62-67. [PMID: 31644325 DOI: 10.1080/02699052.2019.1680867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Objective: To use the electronic medical record (EMR) to optimize patient care, facilitate documentation, and support quality improvement and practice-based research in a concussion (mild traumatic brain injury; mTBI) clinic.Methods: We built a customized structured clinical documentation support (SCDS) toolkit for patients in a concussion specialty clinic. The toolkit collected hundreds of fields of discrete, standardized data. Autoscored and interpreted score tests include the Generalized Anxiety Disorder 7-item scale, Center for Epidemiology Studies Depression scale, Insomnia Severity Index, and Glasgow Coma Scale. Additionally, quantitative score measures are related to immediate memory, concentration, and delayed recall. All of this data collection occurred in a standard appointment length.Results: To date, we evaluated 619 patients at an initial office visit after an mTBI. We provided a description of our toolkit development process, and a summary of the data electronically captured using the toolkit.Conclusions: The electronic medical record can be used to effectively structure and standardize care in a concussion clinic. The toolkit supports the delivery of care consistent with Best Practices, provides opportunities for point of care decision support, and writes comprehensive progress notes that can be communicated to other providers.
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Affiliation(s)
- Kelly Claire Simon
- Department of Neurology, NorthShore University HealthSystem, Evanston, Illinois, USA
| | - Nicole Reams
- Department of Neurology, NorthShore University HealthSystem, Evanston, Illinois, USA
| | - Erik Beltran
- Department of Neurology, NorthShore University HealthSystem, Evanston, Illinois, USA
| | - Charles Wang
- Department of Neurology, NorthShore University HealthSystem, Evanston, Illinois, USA
| | - Bryce Hadsell
- Health Information Technology, NorthShore University HealthSystem, Evanston, Illinois, USA
| | - Darryck Maurer
- Health Information Technology, NorthShore University HealthSystem, Evanston, Illinois, USA
| | - Laura Hillman
- Health Information Technology, NorthShore University HealthSystem, Evanston, Illinois, USA
| | - Samuel Tideman
- Health Information Technology, NorthShore University HealthSystem, Evanston, Illinois, USA
| | - Lisette Garduno
- Department of Neurology, NorthShore University HealthSystem, Evanston, Illinois, USA
| | - Steven Meyers
- Department of Neurology, NorthShore University HealthSystem, Evanston, Illinois, USA
| | - Roberta Frigerio
- Department of Neurology, NorthShore University HealthSystem, Evanston, Illinois, USA
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21
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Kurspahić-Mujčić A, Mujčić A. Preventive health services utilization in patients treated by family physicians. Med Glas (Zenica) 2019; 16. [PMID: 31187610 DOI: 10.17392/1027-19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Revised: 05/07/2019] [Accepted: 05/14/2019] [Indexed: 11/18/2022]
Abstract
Aim To explore preventive health service utilization in patients treated by family physicians and the factors associated with their use. Methods This cross-sectional study was carried out in family medicine outpatient departments of the Primary Health Care Canter of Canton Sarajevo, Bosnia and Herzegovina. The study included 300 patients (150 males and 150 females). A questionnaire for the evaluation of patients' socio-demographic characteristics, health profile and use of preventive health services was used. Results Females visited family physicians significantly more often than males (p=0.001). About 51.2% of males reported undergoing a prostate examination within the past 2 years, 77% of females had an examination of the breast within the past 2 years, 9.8% of males and 10.5% of females had received influenza immunization in past 12 months. A number of visits to family physicians in the last twelve months was significantly associated with having had a prostate examination (digital rectal examination and/or prostate-specific antigen testing) (B=1.413, SE=0.171; p=0.043) and an examination of the breast (clinical breast examination and/or mammography) (B=1.817, SE=0.307; p=0.041). Advancement in age was positively associated with influenza immunization (B=2.901, SE=0.026; p=0.000). Conclusion A visit to family physicians was an important step along the causal pathway to receiving preventive services (a prostate examination, an examination of breast). Adults aged 18-64 years were not well protected against influenza and comprehensive strategies are needed.
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22
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Grant RW, Lyles C, Uratsu CS, Vo MT, Bayliss EA, Heisler M. Visit Planning Using a Waiting Room Health IT Tool: The Aligning Patients and Providers Randomized Controlled Trial. Ann Fam Med 2019; 17:141-149. [PMID: 30858257 PMCID: PMC6411400 DOI: 10.1370/afm.2352] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Revised: 12/20/2018] [Accepted: 12/31/2018] [Indexed: 12/12/2022] Open
Abstract
PURPOSE Time during primary care visits is limited. We tested the hypothesis that a waiting room health information technology (IT) tool to help patients identify and voice their top visit priorities would lead to better visit interactions and improved quality of care. METHODS We designed a waiting room tool, the Visit Planner, to guide adult patients through the process of identifying their top priorities for their visit and effectively expressing these priorities to their clinician. We tested this tool in a cluster-randomized controlled trial with usual care as the control. Eligible patients had at least 1 clinical care gap (eg, overdue for cancer screening, suboptimal chronic disease risk factor control, or medication nonadherence). RESULTS The study (conducted March 31, 2016 through December 31, 2017) included 750 English- or Spanish-speaking patients. Compared with usual care patients, intervention patients more often reported "definitely" preparing questions for their doctor (59.5% vs 45.1%, P <.001) and "definitely" expressing their top concerns at the beginning of the visit (91.3% vs 83.3%, P = .005). Patients in both arms reported high levels of satisfaction with their care (86.8% vs 89.9%, P = .20). With 6 months of follow-up, prevalence of clinical care gaps was reduced by a similar amount in each study arm. CONCLUSIONS A simple waiting room-based tool significantly improved visit communication. Patients using the Visit Planner were more prepared and more likely to begin the visit by communicating their top priorities. These changes did not, however, lead to further reduction in aggregate clinical care gaps beyond the improvements seen in the usual care arm.
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Affiliation(s)
- Richard W Grant
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Courtney Lyles
- Division of Research, Kaiser Permanente Northern California, Oakland, California
- Center for Vulnerable Populations and Division of General Internal Medicine at Zuckerberg San Francisco General Hospital, University of California San Francisco, San Francisco, California
| | - Connie S Uratsu
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Michelle T Vo
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Elizabeth A Bayliss
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, Colorado
- Department of Family Medicine, University of Colorado School of Medicine, Aurora, Colorado
| | - Michele Heisler
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
- University of Michigan Department of Internal Medicine, Ann Arbor, Michigan
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Patel I, Chapman T, Camacho F, Shrestha S, Chang J, Balkrishnan R, Feldman SR. Satisfied patients and pediatricians: a cross-sectional analysis. Patient Relat Outcome Meas 2018; 9:299-307. [PMID: 30214333 PMCID: PMC6118272 DOI: 10.2147/prom.s161621] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Background There is a lack of research in the USA comparing patient satisfaction with pediatricians and other primary care physicians (PCPs). We examined and compared patient satisfaction toward their pediatricians and PCPs and characterized factors associated with higher patient satisfaction in these two groups. Methods A random coefficient model with random slope and intercept was fit to the data, with patient satisfaction as a function of pediatrician/PCP, covariates, and physician random effects. Effect heterogeneity was assessed by allowing slope to vary as a function of covariates. Mediation analysis using the random coefficient model was conducted to calculate average total effect, average natural direct effect, and average indirect effect of pediatrician/PCP on satisfaction mediated by waiting/visit times. Results Pediatricians had higher predicted satisfaction ratings than PCPs (total effect = 4.8, 95% CI 3.7–5.9), with population-averaged mean of 82.2 (0.54) vs 77.4 (0.13). The direct effect was 3.9 (2.8–5.0) and the indirect effect was 0.9 (0.9–0.9), suggesting that part but not all of the total effect can be explained by pediatricians having decreased waiting/visit times leading to increased satisfaction. Predictions by subgroup suggested that pediatricians had lower ratings than PCPs for first visit, but higher ratings for all other covariate strata considered. Having longer waiting times and decreased visit times coincided with closer mean ratings between pediatricians and PCPs, other significant effect modifiers included patient sex, provider sex, and region of practice. Conclusion Pediatricians scored higher patient satisfaction ratings than the combined group of other PCPs. Pediatricians had shorter wait times to see their patients compared to PCPs. Shorter wait times and longer visit times were associated with higher patient satisfaction ratings.
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Affiliation(s)
- Isha Patel
- Department of Pharmacy Practice, Administration and Research, Marshall University School of Pharmacy (MUSOP), Marshall University, Huntington, WV, USA,
| | | | - Fabian Camacho
- Department of Department of Public Health Sciences, School of Medicine, University of Virginia, Charlottesville, VA, USA
| | - Shameen Shrestha
- Bernard J Dunn School of Pharmacy, Shenandoah University, Winchester, VA, USA
| | - Jongwha Chang
- Department of Pharmacy Practice and Clinical Sciences, School of Pharmacy, University of Texas at El Paso, El Paso, TX, USA
| | - Rajesh Balkrishnan
- Department of Department of Public Health Sciences, School of Medicine, University of Virginia, Charlottesville, VA, USA
| | - Steven R Feldman
- Department of Dermatology, Pathology and Public Health Sciences, Wake Forest University School of Medicine, Winston-Salem, NC, USA
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Zhou H, Thompson WW, Belongia EA, Fowlkes A, Baxter R, Jacobsen SJ, Jackson ML, Glanz JM, Naleway AL, Ford DC, Weintraub E, Shay DK. Estimated rates of influenza-associated outpatient visits during 2001-2010 in 6 US integrated healthcare delivery organizations. Influenza Other Respir Viruses 2018; 12:122-131. [PMID: 28960732 PMCID: PMC5818343 DOI: 10.1111/irv.12495] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/27/2017] [Indexed: 12/01/2022] Open
Abstract
Background Population‐based estimates of influenza‐associated outpatient visits including both pandemic and interpandemic seasons are uncommon. Comparisons of such estimates with laboratory‐confirmed rates of outpatient influenza are rare. Objective To estimate influenza‐associated outpatient visits in 6 US integrated healthcare delivery organizations enrolling ~7.7 million persons. Methods Using negative binomial regression methods, we modeled rates of influenza‐associated visits with ICD‐9‐CM‐coded pneumonia or acute respiratory outpatient visits during 2001‐10. These estimated counts were added to visits coded specifically for influenza to derive estimated rates. We compared these rates with those observed in 2 contemporaneous studies recording RT‐PCR‐confirmed influenza outpatient visits. Results Outpatient rates estimated with pneumonia visits were 39 (95% confidence interval [CI], 30‐70) and 203 (95% CI, 180‐240) per 10 000 person‐years, respectively, for interpandemic and pandemic seasons. Corresponding rates estimated with respiratory visits were 185 (95% CI, 161‐255) and 542 (95% CI, 441‐823) per 10 000 person‐years. During the pandemic, children aged 2‐17 years had the largest increase in rates (when estimated with pneumonia visits, from 64 [95% CI, 50‐121] to 381 [95% CI, 366‐481]). Rates estimated with pneumonia visits were consistent with rates of RT‐PCR‐confirmed influenza visits during 4 of 5 seasons in 1 comparison study. In another, rates estimated with pneumonia visits during the pandemic for children and adults were consistent in timing, peak, and magnitude. Conclusions Estimated rates of influenza‐associated outpatient visits were higher in children than adults during pre‐pandemic and pandemic seasons. Rates estimated with pneumonia visits plus influenza‐coded visits were similar to rates from studies using RT‐PCR‐confirmed influenza.
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Affiliation(s)
- Hong Zhou
- Centers for Disease Control & Prevention, Atlanta, GA, USA
| | | | | | - Ashley Fowlkes
- Centers for Disease Control & Prevention, Atlanta, GA, USA
| | - Roger Baxter
- Kaiser Permanente Vaccine Study Center, Oakland, CA, USA
| | - Steven J Jacobsen
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | | | - Jason M Glanz
- Institute for Health Research, Kaiser Permanente, Denver, CO, USA
| | - Allison L Naleway
- Center for Health Research, Kaiser Permanente Northwest, Portland, OR, USA
| | - Derek C Ford
- Centers for Disease Control & Prevention, Atlanta, GA, USA
| | - Eric Weintraub
- Centers for Disease Control & Prevention, Atlanta, GA, USA
| | - David K Shay
- Centers for Disease Control & Prevention, Atlanta, GA, USA
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MacGeorge CA, Simpson KN, Basco WT, Bundy DG. Constipation-Related Emergency Department Use, and Associated Office Visits and Payments Among Commercially Insured Children. Acad Pediatr 2018; 18:952-956. [PMID: 29673883 PMCID: PMC6322666 DOI: 10.1016/j.acap.2018.04.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Revised: 03/29/2018] [Accepted: 04/09/2018] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Pediatric constipation is common, costly, and often managed in the Emergency Department (ED). The objectives of this study were to determine the frequency of constipation-related ED visits in a large commercially insured population, the frequency of an office visit in the month before and after these visits, demographic characteristics associated with these office visits, and the ED-associated payments. METHODS Data were extracted from the Truven MarketScan database for commercially insured children from 2012 to 2013. Data on the presence and timing of clinic visits within 30 days before and after an ED constipation visit and demographic variables were extracted. Logistic regression was used to predict an outcome of presence of a visit with independent variables of age, sex, and region of the country. RESULTS In a population of 17 million children aged 0 to 17 years, 448,440 (2.6%) were identified with constipation in at least 1 setting, with 65,163 (14.5%) having an ED visit for constipation. Of all children with a constipation-related ED visit, 45% had no office visit in the 30 days before or after the ED visit. Increasing age was associated with absence of an office visit. The median payment by insurance for an ED constipation visit was $523, the median out-of-pocket payment was $100, for a total of $623 per visit. CONCLUSION One in 7 children with constipation in this commercially insured population received ED care for constipation, many without an outpatient visit in the month before or after. Efforts to improve primary care utilization for this condition should be encouraged.
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Affiliation(s)
- Claire A MacGeorge
- Department of Pediatrics, Medical University of South Carolina, Charleston, SC.
| | - Kit N Simpson
- Department of Healthcare Leadership and Management, Medical University of South Carolina, Charleston, SC
| | - William T Basco
- Department of Pediatrics, Medical University of South Carolina, Charleston, SC
| | - David G Bundy
- Department of Pediatrics, Medical University of South Carolina, Charleston, SC
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Bohn CE, McQuistan MR, McKernan SC, Askelson NM. Preferences Related to the Use of Mobile Apps as Dental Patient Educational Aids: A Pilot Study. J Prosthodont 2017; 27:329-334. [PMID: 28872732 DOI: 10.1111/jopr.12667] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/18/2017] [Indexed: 11/26/2022] Open
Abstract
PURPOSE Numerous patient education apps have been developed to explain dental treatment. The purpose of this study was to assess perceptions and preferences regarding the use of apps in dental settings. MATERIALS AND METHODS Four patient education apps describing fixed partial dentures were demonstrated to participants (N = 25). Questions about each app were asked using a semi-structured interview format to assess participants' opinions about each app's content, images, features, and use. Sessions were analyzed via note-based methods for thematic coding. RESULTS Participants believed that apps should be used in conjunction with a dentist's explanation about a procedure. They desired an app that could be tailored for scope of content. Participants favored esthetic images of teeth that did not show structural anatomy, such as tooth roots, and preferred interactive features. CONCLUSIONS Patient education apps may be a valuable tool to enhance patient-provider communication in dental settings. Participants exhibited varying preferences for different features among the apps and expressed the desire for an app that could be personalized to each patient. Additional research is needed to assess whether the use of apps improves oral health literacy and informed consent among patients.
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Affiliation(s)
- Courtney E Bohn
- Department of Pediatric Dentistry, Texas A&M University System Baylor College of Dentistry, Dallas, TX
| | - Michelle R McQuistan
- Department of Preventive and Community Dentistry, University of Iowa College of Dentistry and Dental Clinics, Iowa City, IA
| | - Susan C McKernan
- Department of Preventive and Community Dentistry, University of Iowa College of Dentistry and Dental Clinics, Iowa City, IA
| | - Natoshia M Askelson
- Department of Community and Behavioral Health, University of Iowa College of Public Health, Iowa City, IA
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Jepson M, Salisbury C, Ridd MJ, Metcalfe C, Garside L, Barnes RK. The 'One in a Million' study: creating a database of UK primary care consultations. Br J Gen Pract 2017; 67:e345-51. [PMID: 28396369 DOI: 10.3399/bjgp17X690521] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Accepted: 02/08/2017] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND Around 1 million primary care consultations happen in England every day. Despite this, much of what happens in these visits remains a 'black box'. AIM To create an archive of videotaped consultations and linked data based on a large sample of routine face-to-face doctor-patient consultations with consent for use in future research and training. DESIGN AND SETTING Cross-sectional study in 12 general practices in the west of England, UK. METHOD Up to two GPs from each practice took part in the study. Over 1 to 2 days, consecutive patients were approached until up to 20 eligible patients for each GP consented to be videotaped. Eligible patients were aged ≥18 years, consulting on their own behalf, fluent in English, and with capacity to consent. GP questionnaires were self-administered. Patient questionnaires were self-administered immediately pre-consultation and post-consultation, and GPs filled in a checklist after each recording. A follow-up questionnaire was sent to patients after 10 days, and data about subsequent related consultations were collected from medical records 3 months later. RESULTS Of the 485 patients approached, 421 (86.8%) were eligible. Of the eligible patients, 334 (79.3%) consented to participate and 327 consultations with 23 GPs were successfully taped (307 video, 20 audio-only). Most patients (n = 300, 89.8%) consented to use by other researchers, subject to specific ethical approval. CONCLUSION Most patients were willing to allow their consultations to be videotaped, and, with very few exceptions, to allow recordings and linked data to be stored in a data repository for future use for research and training.
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Weinstock MA, Ferris LK, Saul MI, Geller AC, Risica PM, Siegel JA, Solano FX, Kirkwood JM. Downstream consequences of melanoma screening in a community practice setting: First results. Cancer 2016; 122:3152-3156. [PMID: 27391802 DOI: 10.1002/cncr.30177] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2015] [Revised: 02/10/2016] [Accepted: 02/12/2016] [Indexed: 11/07/2022]
Abstract
BACKGROUND Population-based screening for the early detection of melanoma holds great promise for reducing melanoma mortality, but evidence is needed to determine whether benefits outweigh risks. Skin surgeries and dermatology visits after screening were assessed to indicate potential physical, psychological, and financial consequences. METHODS Targeted primary care providers (PCPs) at the University of Pittsburgh Medical Center were trained to detect early melanoma using the INFORMED (INternet course FOR Melanoma Early Detection) program. The authors analyzed aggregated administrative data describing 3 groups of patients aged ≥35 years who had received an annual physical examination by PCPs: group A1 included patients of PCPs from the group with the highest percentage of INFORMED-trained providers, group A2 included patients of PCPs from the group with a lower percentage of INFORMED-trained providers, and group B included patients of PCPs without INFORMED training. RESULTS INFORMED-trained PCPs screened 1572 of 16,472 patients in groups A1 or A2 and none of the 56,261 patients in group B. In group A1, there was a 79% increase (95% confidence interval, 15%-138%) in melanoma diagnoses noted; no increase was observed for the other groups, and no substantial increase in skin surgeries or dermatology visits occurred in any group. CONCLUSIONS A large-scale melanoma screening using the INFORMED program was conducted in Pennsylvania. To the best of the authors' knowledge, the current study is the first analysis of downstream results and the findings indicate increased melanoma diagnoses but little impact on skin surgeries or dermatology visits. This result provides some reassurance that such efforts can be conducted without major adverse consequences, at least as measured by these parameters, and therefore should be considered for more widespread use. Cancer 2016;122:3152-6. © 2016 American Cancer Society.
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Affiliation(s)
- Martin A Weinstock
- Center for Dermatoepidemiology, Providence VA Medical Center, Providence, Rhode Island. .,Departments of Dermatology and Epidemiology, Brown University, Providence, Rhode Island.
| | - Laura K Ferris
- Department of Dermatology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Melissa I Saul
- Department of Biomedical Informatics, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Alan C Geller
- Department of Social and Behavioral Sciences, Harvard School of Public Health, Boston, Massachusetts
| | - Patricia M Risica
- Department of Epidemiology, Brown University, Providence, Rhode Island
| | - Julia A Siegel
- Center for Dermatoepidemiology, Providence VA Medical Center, Providence, Rhode Island
| | - Francis X Solano
- Physician Services Division, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - John M Kirkwood
- Melanoma and Skin Cancer Program, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
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Belkora JK, Miller MF, Dougherty K, Gayer C, Golant M, Buzaglo JS. The need for decision and communication aids: a survey of breast cancer survivors. J Community Support Oncol 2016; 13:104-12. [PMID: 25880673 DOI: 10.12788/jcso.0116] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 11/05/2014] [Indexed: 11/20/2022]
Abstract
BACKGROUND Qualitative studies have identified barriers to communication and informed decision making among breast cancer survivors making treatment decisions. The prevalence of these barriers is unknown. OBJECTIVE To quantify the need for decision support among breast cancer survivors. METHODS We surveyed 2,521 breast cancer survivors participating in an online registry hosted by the Cancer Support Community to find out what proportion of breast cancer patients: made decisions during their first visit with a specialist; received satisfactory information before that visit; asked questions and received responses; and endorsed expanded use of decision support. RESULTS We received 1,017 (41%) responses and analyzed 917 surveys from women who lived in the United States. Most of the respondents recalled making treatment decisions during their first visit (52%). A minority (14%) received information before the first specialist visit. At least 25% of respondents rated their satisfaction below 7 on a scale of 10 for decision-making, information, and questions asked and answered. Respondents endorsed the need for assistance with obtaining information, listing questions, taking notes, and making audio-recordings of visits. LIMITATIONS The respondent sample skewed younger and had higher-stage cancer compared with all breast cancer survivors. Responses were subject to recall bias. CONCLUSIONS Cancer survivors expressed gaps in their care with respect to reviewing information, asking questions, obtaining answers, and making decisions. Implementing decision and communication aids immediately upon diagnosis, when treatment decisions are being made, would address these gaps.
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Affiliation(s)
- Jeffrey K Belkora
- Institute for Health Policy Studies, University of California, San Francisco, California, USA
| | | | | | - Christopher Gayer
- Research & Training Institute, Cancer Support Community, Philadelphia, Pennsylvania, USA
| | - Mitch Golant
- Research & Training Institute, Cancer Support Community, Philadelphia, Pennsylvania, USA
| | - Joanne S Buzaglo
- Research & Training Institute, Cancer Support Community, Philadelphia, Pennsylvania, USA.
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Pais VM, Smith RE, Stedina EA, Rissman CM. Does Omission of Ureteral Stents Increase Risk of Unplanned Return Visit? A Systematic Review and Meta-Analysis. J Urol 2016; 196:1458-1466. [PMID: 27287523 DOI: 10.1016/j.juro.2016.05.109] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/31/2016] [Indexed: 01/22/2023]
Abstract
PURPOSE Post-ureteroscopy ureteral stent omission remains controversial. Although omission is associated with reduced postoperative discomfort, concern remains for early obstruction. We performed a systematic review and meta-analysis of trials to compare the risk of unplanned visits with vs without a stent following ureteroscopy for nephrolithiasis. MATERIALS AND METHODS Randomized, controlled trials and observational studies comparing post-ureteroscopic stent omission vs placement and reporting unplanned visits within 30 days were identified via a search of MEDLINE® (1946 to 2015), CENTRAL (Cochrane Central Register of Controlled Trials, 1898 to 2015), Embase® (1947 to 2015), ClinicalTrials.gov (1997 to 2015), AUA (American Urological Association) Annual Meeting abstracts (2011 to 2015) and reference lists of included articles as last updated in October 2015. Two reviewers independently extracted data and assessed methodological quality. ORs, RRs and weighted mean differences were calculated as appropriate for each outcome. RESULTS Of the initial 1,992 studies 17 in a total of 1,943 participants met inclusion criteria. Unstented patients were significantly more likely to have an unplanned medical visit compared to those who received a post-ureteroscopy stent (OR 1.63, 95% CI 1.15-2.30). Unstented patients had shorter operative time (weighted mean difference -3.19 minutes, 95% CI -5.64--0.74) and were less likely to experience dysuria (RR 0.39, 95% CI 0.25-0.62). They were also less likely to experience postoperative infection (OR 0.89, 95% CI 0.59-1.33) and pain (OR 0.64, 95% CI 0.39-1.05), although these results were not significant. CONCLUSIONS Stent omission is associated with an increased risk of unplanned medical visits despite reduced symptoms compared to those in stented patients. Patients and physicians should weigh these trade-offs when considering post-ureteroscopy stent placement.
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Affiliation(s)
- Vernon M Pais
- Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire; Geisel School of Medicine at Dartmouth, Hanover, New Hampshire.
| | - Rebecca E Smith
- Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire
| | - Elizabeth A Stedina
- Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire
| | - Cody M Rissman
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
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Hepp Z, Rosen NL, Gillard PG, Varon SF, Mathew N, Dodick DW. Comparative effectiveness of onabotulinumtoxinA versus oral migraine prophylactic medications on headache-related resource utilization in the management of chronic migraine: Retrospective analysis of a US-based insurance claims database. Cephalalgia 2015; 36:862-74. [PMID: 26692400 DOI: 10.1177/0333102415621294] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2015] [Accepted: 11/17/2015] [Indexed: 11/15/2022]
Abstract
BACKGROUND Migraine, especially chronic migraine (CM), causes substantial disability; however, health care utilization has not been well characterized among patients receiving different migraine prophylactic treatments. METHODS Using a large, US-based, health care claims database, headache-related health care utilization was evaluated among adults with CM treated with onabotulinumtoxinA or oral migraine prophylactic medications (OMPMs). Headache-related health care utilization was assessed at six, nine, and 12 months pre- and post-treatment. The primary endpoint was the difference between pre- and post-index headache-related health care utilization. A logistic regression model was created to test the difference between onabotulinumtoxinA and OMPM-treated groups for headache-related emergency department (ED) visits and hospitalizations. RESULTS Baseline characteristics were comparable between groups. The proportion of patients with ED visits or hospitalizations for a headache-related event decreased after starting onabotulinumtoxinA, but increased after starting an OMPM, for all three cohorts. Regression analyses showed that the odds of having a headache-related ED visit were 21%, 20%, and 19% lower and hospitalization were 47%, 48%, and 56% lower for the onabotulinumtoxinA group compared to the OMPM group for the six-month, nine-month, and 12-month post-index periods, respectively. CONCLUSIONS When compared with similar patients who initiated treatment with OMPM, onabotulinumtoxinA was associated with a significantly lower likelihood of headache-related ED visits and hospitalizations.
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Affiliation(s)
- Zsolt Hepp
- Global Health Economics and Outcomes Research, Allergan plc, USA
| | | | | | - Sepideh F Varon
- Global Health Economics and Outcomes Research, Allergan plc, USA
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Stettler N, Wrotniak BH, Hill DL, Kumanyika SK, Xanthopoulos MS, Nihtianova S, Shults J, Leff SS, Pinto A, Berkowitz RI, Faith MS. Prevention of excess weight gain in paediatric primary care: beverages only or multiple lifestyle factors. The Smart Step Study, a cluster-randomized clinical trial. Pediatr Obes 2015; 10:267-74. [PMID: 25251166 PMCID: PMC4372512 DOI: 10.1111/ijpo.260] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2013] [Revised: 06/19/2014] [Accepted: 07/22/2014] [Indexed: 01/08/2023]
Abstract
BACKGROUND Insufficient evidence exists to support obesity prevention in paediatric primary care. OBJECTIVES To test a theory-based behaviour modification intervention delivered by trained paediatric primary care providers for obesity prevention. METHODS Efficacy trial with cluster randomization (practice level) and a 12-session 12-month sweetened beverages decrease intervention or a comprehensive dietary and physical activity intervention, compared with a control intervention among children ages 8-12 years. RESULTS A low recruitment rate was observed. The increase in body mass index z-score (BMIz) for the 139 subjects (11 practices) randomized to any of the two obesity interventions (combined group) was less than that of the 33 subjects (five practices) randomized to the control intervention (-0.089, 95% confidence interval [CI]: -0.170 to -0.008, P = 0.03) with a -1.44 kg weight difference (95% CI: -2.98 to +0.10 kg, P = 0.095). The incidences of obesity and excess weight gain were lower in the obesity interventions, but the number of subjects was small. Post hoc analyses comparing the beverage only to the control intervention also showed an intervention benefit on BMIz (-0.083, 95% CI: -0.165 to -0.001, P = 0.048). CONCLUSIONS For participating families, an obesity prevention intervention delivered by paediatric primary care clinicians, who are compensated, trained and continuously supported by behavioural specialists, can impact children's BMIz.
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Affiliation(s)
| | - Brian H. Wrotniak
- D’Youville College, Buffalo, NY,The Children’s Hospital of Philadelphia, Philadelphia, PA
| | | | | | | | | | - Justine Shults
- The Children’s Hospital of Philadelphia, Philadelphia, PA,Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Stephen S. Leff
- The Children’s Hospital of Philadelphia, Philadelphia, PA,Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Andres Pinto
- Case Western Reserve University School of Dental Medicine, Cleveland, OH
| | - Robert I. Berkowitz
- The Children’s Hospital of Philadelphia, Philadelphia, PA,Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Myles S. Faith
- Gillings School of Global Public Health University of North Carolina - Chapel Hill, Chapel Hill, NC
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Abstract
PURPOSE Previous studies suggest that the highest-risk patients value accessible, coordinated primary care that they perceive to be of high technical quality. We have limited understanding, however, of how low-income, chronically ill patients and the staff who care for them experience each individual step in the primary care process. METHODS We conducted qualitative interviews with uninsured or Medicaid patients with chronic illnesses, as well as with primary care staff. We interviewed 21 patients and 30 staff members with a variety of job titles from 3 primary care practices (1 federally qualified health center and 2 academically affiliated clinics).] RESULTS The interviews revealed 3 major issues that were present at all stages of a primary care episode: (1) information flow throughout an episode of care is a frequent challenge, despite systems that are intended to improve communication; (2) misaligned goals and expectations among patients, clinicians, and staff members are often an impediment to providing and obtaining care; and (3) personal relationships are highly valued by both patients and staff. CONCLUSIONS Vulnerable populations and the primary care staff who work with them perceive some of the same challenges throughout the primary care process. Improving information flow, aligning goals and expectations, and developing personal relationships may improve the experience of both patients and staff.
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Affiliation(s)
- Elizabeth J Brown
- The Robert Wood Johnson Foundation Clinical Scholars Program, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania The Department of Family and Community Medicine, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Shreya Kangovi
- The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania The Division of General Internal Medicine, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania Penn Center for Community Health Workers, Philadelphia, Pennsylvania
| | - Christopher Sha
- Department of Medicine, University of San Francisco, San Francisco, California
| | - Sarah Johnson
- Department of Internal Medicine, Johns Hopkins Hospital, Baltimore, Maryland
| | - Casey Chanton
- Penn Center for Community Health Workers, Philadelphia, Pennsylvania
| | - Tamala Carter
- Penn Center for Community Health Workers, Philadelphia, Pennsylvania
| | - David T Grande
- The Robert Wood Johnson Foundation Clinical Scholars Program, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania The Division of General Internal Medicine, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania
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Liss DT, Reid RJ, Grembowski D, Rutter CM, Ross TR, Fishman PA. Changes in office visit use associated with electronic messaging and telephone encounters among patients with diabetes in the PCMH. Ann Fam Med 2014; 12:338-43. [PMID: 25024242 PMCID: PMC4096471 DOI: 10.1370/afm.1642] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
PURPOSE Telephone- and Internet-based communication are increasingly common in primary care, yet there is uncertainty about how these forms of communication affect demand for in-person office visits. We assessed whether use of copay-free secure messaging and telephone encounters was associated with office visit use in a population with diabetes. METHODS We used an interrupted time series design with a patient-quarter unit of analysis. Secondary data from 2008-2011 spanned 3 periods before, during, and after a patient-centered medical home (PCMH) redesign in an integrated health care delivery system. We used linear regression models to estimate proportional changes in the use of primary care office visits associated with proportional increases in secure messaging and telephone encounters. RESULTS The study included 18,486 adults with diabetes. The mean quarterly number of primary care contacts increased by 28% between the pre-PCMH baseline and the postimplementation periods, largely driven by increased secure messaging; quarterly office visit use declined by 8%. In adjusted regression analysis, 10% increases in secure message threads and telephone encounters were associated with increases of 1.25% (95% CI, 1.21%-1.29%) and 2.74% (95% CI, 2.70%-2.77%) in office visits, respectively. In an interaction model, proportional increases in secure messaging and telephone encounters remained associated with increased office visit use for all study periods and patient subpopulations (P<.001). CONCLUSIONS Before and after a medical home redesign, proportional increases in secure messaging and telephone encounters were associated with additional primary care office visits for individuals with diabetes. Our findings provide evidence on how new forms of patient-clinician communication may affect demand for office visits.
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Affiliation(s)
- David T Liss
- Division of General Internal Medicine and Geriatrics, Northwestern University Fein-berg School of Medicine, Chicago, Illinois Group Health Research Institute, Seattle, Washington
| | - Robert J Reid
- Group Health Research Institute, Seattle, Washington Department of Health Services, University of Washington School of Public Health, Seattle, Washington
| | - David Grembowski
- Group Health Research Institute, Seattle, Washington Department of Health Services, University of Washington School of Public Health, Seattle, Washington
| | - Carolyn M Rutter
- Group Health Research Institute, Seattle, Washington Department of Health Services, University of Washington School of Public Health, Seattle, Washington Department of Biostatistics, University of Washington School of Public Health, Seattle, Washington
| | - Tyler R Ross
- Group Health Research Institute, Seattle, Washington
| | - Paul A Fishman
- Group Health Research Institute, Seattle, Washington Department of Health Services, University of Washington School of Public Health, Seattle, Washington
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Will JC, Loustalot F, Hong Y. National trends in visits to physician offices and outpatient clinics for angina 1995 to 2010. Circ Cardiovasc Qual Outcomes 2014; 7:110-7. [PMID: 24425707 DOI: 10.1161/circoutcomes.113.000450] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND We asked whether visits to physician offices and hospital outpatient clinics for angina have changed over time and whether more frequent use of certain diagnostic techniques or referrals in this setting may account for such changes. METHODS AND RESULTS We combined data from the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey to study visits to physician offices and outpatient departments. We calculated both crude and standardized rates for these visits using a modified version of technical specifications published by the Agency for Healthcare Research and Quality. In 1995 to 1998, there were on average 3.6 million office/clinic visits each year for angina among adults in the United States. By 2007 to 2010, this had declined to 2.3 million visits each year. Angina visit rates per 100,000 declined significantly (P<0.05), with the greatest decline from 1995 through 1998 to 2003 through 2007. Coronary atherosclerotic disease diagnoses also declined after 2002. Both stress testing and referring patients out for care doubled during some study periods. CONCLUSIONS Office and clinic visits for angina have declined over time. This trend parallels findings for both preventable hospitalization and emergency room visits for angina. Previous research's decline in angina hospitalizations is not likely attributable to decreased referrals to hospital and emergency rooms for diagnosis and management. Although changes in International Classification of Diseases, Ninth Revision, Clinical Modification coding guidelines may explain some of the decline in angina and coronary atherosclerotic disease visits, it seems that other factors such as improved treatment or prevention may have played an additional role.
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Affiliation(s)
- Julie C Will
- Division for Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention, Atlanta, GA
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Jung YH, Song CM, Park JH, Kim H, Cha W, Hah JH, Kwon TK, Kim KH, Sung MW. Efficacy of current regular follow-up policy after treatment for head and neck cancer: Need for individualized and obligatory follow-up strategy. Head Neck 2013; 36:715-21. [PMID: 23616261 DOI: 10.1002/hed.23364] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2012] [Revised: 03/11/2013] [Accepted: 04/11/2013] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND The purpose of this study was to report the efficacy of routine follow-up after head and neck cancer treatment. METHOD Data for 520 patients with head and neck cancer registered with between 2002 and 2008 were reviewed retrospectively. RESULTS The mean ± SD follow-up period taken into account was 34.7 ± 22.8 months. The pickup rate for recurrence using our follow-up protocol in this cohort was 1 in every 79 visits (1.26%). High pickup rates were observed in patients older than 70 years and patients with advanced T classification, whereas low pickup rates were observed in patients who had received treatment including surgery. The only factor on multivariate analysis to influence follow-up visits was surgical treatment (p = .043). CONCLUSION Individualized and obligatory follow-up policy is desirable considering various factors, especially age, T classification, and whether treatment modality includes surgery or not.
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Affiliation(s)
- Young Ho Jung
- Department of Otolaryngology - Head and Neck Surgery, Seoul National University Boramae Hospital, Seoul, Korea
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Cheraghi-Sohi S, Hole AR, Mead N, McDonald R, Whalley D, Bower P, Roland M. What patients want from primary care consultations: a discrete choice experiment to identify patients' priorities. Ann Fam Med 2008; 6:107-15. [PMID: 18332402 PMCID: PMC2267425 DOI: 10.1370/afm.816] [Citation(s) in RCA: 167] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
PURPOSE The consultation is fundamental to the delivery of primary care, but different ways of organizing consultations may lead to different patient experiences in terms of access, continuity, technical quality of care, and communication. Patients' priorities for these different issues need to be understood, but the optimal methods for assessing priorities are unclear. This study used a discrete choice experiment to assess patients' priorities. METHODS We surveyed patients from 6 family practices in England. The patients chose between primary care consultations differing in attributes such as ease of access (wait for an appointment), choice (flexibility of appointment times), continuity (physician's knowledge of the patient), technical quality (thoroughness of physical examination), and multiple aspects of patient-centered care (interest in patient's ideas, inquiry about patient's social and emotional well-being, and involvement of patient in decision making). We used probit models to assess the relative priority patients placed on different attributes and to estimate how much they were willing to pay for them. RESULTS Analyses were based on responses from 1,193 patients (a 53% response rate). Overall, patients were willing to pay the most for a thorough physical examination ($40.87). The next most valued attributes of care were seeing a physician who knew them well ($12.18), seeing a physician with a friendly manner ($8.50), having a reduction in waiting time of 1 day ($7.22), and having flexibility of appointment times ($6.71). Patients placed similar value on the different aspects of patient-centered care ($12.06-$14.82). Responses were influenced by the scenario in which the decision was made (minor physical problem vs urgent physical problem vs ambiguous physical or psychological problem) and by patients' demographic characteristics. CONCLUSIONS Although patient-centered care is important to patients, they may place higher priority on the technical quality of care and continuity of care. Discrete choice experiments may be a useful method for assessing patients' priorities in health care.
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Affiliation(s)
- Sudeh Cheraghi-Sohi
- National Primary Care Research and Development Centre (NPCRDC), University of Manchester, Manchester, United Kingdom
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Galliher JM, Stewart TV, Pathak PK, Werner JJ, Dickinson LM, Hickner JM. Data collection outcomes comparing paper forms with PDA forms in an office-based patient survey. Ann Fam Med 2008; 6:154-60. [PMID: 18332408 PMCID: PMC2267414 DOI: 10.1370/afm.762] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
PURPOSE We compared the completeness of data collection using paper forms and using electronic forms loaded on handheld computers in an office-based patient interview survey conducted within the American Academy of Family Physicians National Research Network. METHODS We asked 19 medical assistants and nurses in family practices to administer a survey about pneumococcal immunizations to 60 older adults each, 30 using paper forms and 30 using electronic forms on handheld computers. By random assignment, the interviewers used either the paper or electronic form first. Using multilevel analyses adjusted for patient characteristics and clustering of forms by practice, we analyzed the completeness of the data. RESULTS A total of 1,003 of the expected 1,140 forms were returned to the data center. The overall return rate was better for paper forms (537 of 570, 94%) than for electronic forms (466 of 570, 82%) because of technical difficulties experienced with electronic data collection and stolen or lost handheld computers. Errors of omission on the returned forms, however, were more common using paper forms. Of the returned forms, only 3% of those gathered electronically had errors of omission, compared with 35% of those gathered on paper. Similarly, only 0.04% of total survey items were missing on the electronic forms, compared with 3.5% of the survey items using paper forms. CONCLUSIONS Although handheld computers produced more complete data than the paper method for the returned forms, they were not superior because of the large amount of missing data due to technical difficulties with the hand-held computers or loss or theft. Other hardware solutions, such as tablet computers or cell phones linked via a wireless network directly to a Web site, may be better electronic solutions for the future.
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Affiliation(s)
- James M Galliher
- AAFP National Research Network, American Academy of Family Physicians, 11400 Tomahawk Creek Pkwy, Leawood, KS 66211, USA.
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Ohman-Strickland PA, Orzano AJ, Hudson SV, Solberg LI, DiCiccio-Bloom B, O'Malley D, Tallia AF, Balasubramanian BA, Crabtree BF. Quality of diabetes care in family medicine practices: influence of nurse-practitioners and physician's assistants. Ann Fam Med 2008; 6:14-22. [PMID: 18195310 PMCID: PMC2203407 DOI: 10.1370/afm.758] [Citation(s) in RCA: 85] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
PURPOSE The aim of this study was to assess whether the quality of diabetes care differs among practices employing nurse-practitioners (NPs), physician's assistants (PAs), or neither, and which practice attributes contribute to any differences in care. METHODS This cross-sectional study of 46 family medicine practices from New Jersey and Pennsylvania measured adherence to American Diabetes Association diabetes guidelines via chart audits of 846 patients with diabetes. Practice characteristics were identified by staff surveys. Hierarchical models determined differences between practices with and without NPs or PAs. RESULTS Compared with practices employing PAs, practices employing NPs were more likely to measure hemoglobin A(1c) levels (66% vs 33%), lipid levels (80% vs 58%), and urinary microalbumin levels (32% vs 6%); to have treated for high lipid levels (77% vs 56%); and to have patients attain lipid targets (54% vs 37%) (P <or= .005 for each). Practices with NPs were more likely than physician-only practices to assess hemoglobin A(1c) levels (66% vs 49%) and lipid levels (80% vs 68%) (P<or=.007 for each). These effects could not be attributed to use of diabetes registries, health risk assessments, nurses for counseling, or patient reminder systems. Practices with either PAs or NPs were perceived as busier (P=.03) and had larger total staff (P <.001) than physician-only practices. CONCLUSIONS Family practices employing NPs performed better than those with physicians only and those employing PAs, especially with regard to diabetes process measures. The reasons for these differences are not clear.
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Rothemich SF, Woolf SH, Johnson RE, Burgett AE, Flores SK, Marsland DW, Ahluwalia JS. Effect on cessation counseling of documenting smoking status as a routine vital sign: an ACORN study. Ann Fam Med 2008; 6:60-8. [PMID: 18195316 PMCID: PMC2203392 DOI: 10.1370/afm.750] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2006] [Revised: 05/15/2007] [Accepted: 06/04/2007] [Indexed: 11/09/2022] Open
Abstract
PURPOSE Guidelines encourage primary care clinicians to document smoking status when obtaining patients' blood pressure, temperature, and pulse rate (vital signs), but whether this practice promotes cessation counseling is unclear. We examined whether the vital sign intervention influences patient-reported frequency and intensity of tobacco cessation counseling. METHODS This study was a cluster-randomized, controlled trial conducted in the Virginia Ambulatory Care Outcomes Research Network (ACORN). At intervention practices, nurses and medical assistants were instructed to assess the tobacco use status of every adult patient and record it with the traditional vital signs. Control practices did not use any systematic tobacco screening or identification system. Outcomes were the proportion of smokers reporting clinician counseling of any kind and the frequency of 2 counseling subcomponents: simple quit advice and more intensive discussion. RESULTS A total of 6,729 adult patients (1,149 smokers) at 18 primary care practices completed exit questionnaires during a 6-month comparison period. Among 561 smokers at intervention practices, 61.9% reported receiving any counseling, compared with 53.4% of the 588 smokers at control practices, for a difference of 8.6% (P = .04). The effect was largely restricted to simple advice, which was reported by 59.9% of intervention patients and 51.5% of control patients (P=.04). There was no significant increase in more extensive discussion, with 32.5% and 29.3% of patients at intervention and control practices, respectively, reporting this type of counseling (P=.18). CONCLUSIONS The vital sign intervention promotes tobacco counseling at primary care practices through a modest increase in simple advice to quit. When implemented as a stand-alone intervention, it does not appear to increase intensive counseling.
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Affiliation(s)
- Stephen F Rothemich
- Department of Family Medicine, Virginia Commonwealth University, Richmond, VA 23298-0251, USA.
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Abstract
PURPOSE This study investigated the effect of a simple visual prompt in the form of a poster on the occurrence of patient-physician weight loss conversations during routine office encounters in a primary care outpatient clinic. METHODS We conducted a 2-phase study in a family medicine residency program outpatient clinic in August and September 2006. During the first phase, lasting 5 days, we surveyed all nonpregnant adult patients (preintervention group) about weight loss. We then implemented a visual prompt in the form of a colorful poster (11 x 17 inches) in both English and Spanish. The poster read "Do you want to lose weight? Ask your doctor today!" and included a picture of a bathroom scale. During the second phase, also lasting 5 days, we again surveyed all nonpregnant adult patients (postintervention group). RESULTS Analyses were based on 283 patients in the preintervention group and 386 patients in the postintervention group. The mean body mass index, obtained from medical records, did not differ significantly between groups (31 vs 32 kg/m2, respectively). Fully 60% of patients in the postintervention group recalled seeing the poster during their visit; however, the percentage of patients who reported discussing weight loss with their physician did not differ between the preintervention and postintervention groups overall (29% vs 27%), among the two-thirds of patients who wanted to lose weight (26% vs 23%), or when only postintervention patients who saw the poster were included in the comparison (29% vs 29%). The large majority of patients in both groups who had such discussions--82% and 77%--indicated that they found them useful; the difference between groups was not significant. CONCLUSION A simple visual prompt in the form of a poster directed at patients did not increase the occurrence of conversations between patients and their physicians about weight loss.
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Affiliation(s)
- Gillian S Stephens
- Department of Community and Family Medicine, Saint Louis University, St Louis, Missouri 63104, USA.
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Abstract
PURPOSE The purpose of this study was to ascertain physician characteristics associated with exploring suicidality in patients with depressive symptoms and the influence of patient antidepressant requests. METHODS Primary care physicians were randomly recruited from 4 sites in northern California and Rochester, NY; 152 physicians participated (53%-61% of those approached). Standardized patients portraying 2 conditions (major depression and adjustment disorder) and 3 antidepressant request types (brand specific, general, or none) made unannounced visits to these physicians between May 2003 and May 2004. We examined factors associated with physician exploration of suicidality. RESULTS Suicide was explored in 36% of 298 encounters. Exploration was more common when the patient portrayed major depression (vs adjustment disorder) (P = .03), with an antidepressant request (vs no request) (P=.02), in academic settings (P <.01), and among physicians with personal experience with depression (P <.01). The random effects logistic model revealed a significant physician variance component with rho = 0.57 (95% confidence interval, 0.45-0.68) indicating that there were additional, unspecified physician factors determining the tendency to explore suicide risk. These factors are unrelated to physician specialty (family medicine or internal medicine), sex, communication style, or perceived barriers to or confidence in treating depression. CONCLUSIONS When seeing patients with depressive symptoms, primary care physicians do not consistently inquire about suicidality. Their inquiries into suicidal thinking may be enhanced through advertising or public service messaging that prompts patients to ask for help. Research is needed to further elucidate physician characteristics associated with the assessment of suicidality.
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Affiliation(s)
- Mitchell D Feldman
- Division of General Internal Medicine, Department of Medicine, University of California, San Francisco, Calif, USA
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González-González AI, Dawes M, Sánchez-Mateos J, Riesgo-Fuertes R, Escortell-Mayor E, Sanz-Cuesta T, Hernández-Fernández T. Information needs and information-seeking behavior of primary care physicians. Ann Fam Med 2007; 5:345-52. [PMID: 17664501 PMCID: PMC1934982 DOI: 10.1370/afm.681] [Citation(s) in RCA: 114] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
PURPOSE The aim of this study was to determine the information needs of primary care physicians in Spain and to describe their information-seeking patterns. METHODS This observational study took place in primary care practices located in Madrid, Spain. Participants were a random stratified sample of 112 primary care physicians. Physicians' consultations were video recorded for 4 hours. Clinical questions arising during the patient visit and the sources of information used within the consultation to answer questions were identified. Physicians with unanswered questions were followed up by telephone 2 weeks later to determine whether their questions had since been answered and the sources of information used. Clinical questions were classified by topic and type of information. RESULTS A total of 3,511 patient consultations (mean length, 7.8 minutes) were recorded, leading to 635 clinical questions (0.18 questions per consultation). The most frequent questions were related to diagnosis (53%) and treatment (26%). The most frequent generic type of questions was "What is the cause of symptom x?" (20.5%). Physicians searched for answers to 22.8% of the questions (9.6% during consultations). The time taken and the success rate in finding an answer during a consultation and afterward were 2 minutes (100%) and 32 minutes (75%), respectively. CONCLUSIONS Primary care physicians working in settings where consultations are of short duration have time to answer only 1 in 5 of their questions. Better methods are needed to provide answers to questions that arise in office practice in settings where average consultation time is less than 10 minutes.
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Abstract
PURPOSE This study aimed to examine the contribution of competing demands to changes in hypoglycemic medications and to return appointment intervals for patients with type 2 diabetes and an elevated glycosylated hemoglobin (A1c) level. METHODS We observed 211 primary care encounters by adult patients with type 2 diabetes in 20 primary care clinics and documented changes in hypoglycemic medications. Competing demands were assessed from length of encounter, number of concerns patients raised, and number of topics brought up by the clinician. Days to the next scheduled appointment were obtained at patient checkout. Recent A1c values and dates were determined from the chart. RESULTS Among patients with an A(1c) level greater than 7%, each additional patient concern was associated with a 49% (95% confidence interval, 35%-60%) reduction in the likelihood of a change in medication, independent of length of the encounter and most recent level of A1c. Among patients with an A(1c) level greater than 7% and no change in medication, for every additional minute of encounter length, the time to the next scheduled appointment decreased by 2.8 days (P = .001). Similarly, for each additional 1% increase in A1c level, the time to the next scheduled appointment decreased by 8.6 days (P=.001). CONCLUSIONS The concept of clinical inertia is limited and does not fully characterize the complexity of primary care encounters. Competing demands is a principle for constructing models of primary care encounters that are more congruent with reality and should be considered in the design of interventions to improve chronic disease outcomes in primary care settings.
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Affiliation(s)
- Michael L Parchman
- VERDICT Health Services Research Center, South Texas Veterans Health Care System, San Antonio, Tex 78229-4404, USA.
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Binns HJ, Lanier D, Pace WD, Galliher JM, Ganiats TG, Grey M, Ariza AJ, Williams R. Describing primary care encounters: the Primary Care Network Survey and the National Ambulatory Medical Care Survey. Ann Fam Med 2007; 5:39-47. [PMID: 17261863 PMCID: PMC1783926 DOI: 10.1370/afm.620] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2005] [Revised: 05/22/2006] [Accepted: 05/30/2006] [Indexed: 11/09/2022] Open
Abstract
PURPOSE The purpose of this study was to describe clinical encounters in primary care research networks and compare them with those of the National Ambulatory Medical Care Survey (NAMCS). METHODS Twenty US primary care research networks collected data on clinicians and patient encounters using the Primary Care Network Survey (PRINS) Clinician Interview (PRINS-1) and Patient Record (PRINS-2), which were newly developed based on NAMCS tools. Clinicians completed a PRINS-1 about themselves and a PRINS-2 for each of 30 patient visits. Data included patient characteristics; reason for the visit, diagnoses, and services ordered or performed. We compared PRINS data with data obtained from primary care physicians during 5 cycles of NAMCS (1997-2001). Data were weighted; PRINS reflects participating networks and NAMCS provides national estimates. RESULTS By discipline, 89% of PRINS clinicians were physicians, 4% were physicians in residency training, 5% were advanced practice nurses/nurse-practitioners, and 2% were physician's assistants. The majority (53%) specialized in pediatrics (34% specialized in family medicine, 9% in internal medicine, and 4% in other specialties). All NAMCS clinicians were physicians, with 20% specializing in pediatrics. When NAMCS and PRINS visits were compared, larger proportions of PRINS visits involved preventive care and were made by children, members of minority racial groups, and individuals who did not have private health insurance. A diagnostic or other assessment service was performed for 99% of PRINS visits and 76% of NAMCS visits (95% confidence interval, 74.9%-78.0%). A preventive or counseling/education service was provided at 64% of PRINS visits and 37% of NAMCS visits (95% confidence interval, 35.1%-38.0%). CONCLUSIONS PRINS presents a view of diverse primary care visits and differs from NAMCS in its methods and findings. Further examinations of PRINS data are needed to assess their usefulness for describing encounters that occur in primary care research networks.
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Affiliation(s)
- Helen J Binns
- Pediatric Practice Research Group, Mary Ann and J. Milburn Smith Child Health Research Program, Children's Memorial Research Center, Children's Memorial Hospital, Chicago, IL, USA.
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Abstract
This essay presents a family medicine office visit with a child and both parents; details have been modified to protect patient and physician confidentiality. A child's headache, which has gone away before the start of the office visit, provides a window into the relationship between the parents and into the sources of their worries about their child's health. The essay highlights the multiple medical and behavioral concerns that the physician must keep in mind during relatively brief office encounters, and the intellectual challenge of maintaining appropriate attention to all these threads, and understanding their interactions, while completing the visit in a timely fashion.
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Affiliation(s)
- Howard Brody
- Department of Family Practice, Michigan, State University, East Lansing, MI, USA.
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Abstract
BACKGROUND Older patients mostly receive depression care from primary care physicians, but it is not known whether depression treatment is primarily received from family/general practice physicians or internal medicine physicians and whether the type of depression treatment offered varies between these types of primary care physicians. OBJECTIVE To assess what proportion of visits for depression are to family/general practice physicians or to internal medicine physicians and whether the type of depression treatment offered varies by primary care physician specialty. DESIGN Data from the 2000 and 2001 National Ambulatory Medical Care Surveys, a nationally representative survey of visits to office-based practices using clustered sampling, were used. PARTICIPANTS Office-based physician practices in the United States. RESULTS There were an estimated 9.8 million visits made to office-based providers by older patients for depression in 2001 to 2002, of which 64% were to primary care physicians. Visits to primary care providers were evenly split between Internists and family/general practice physicians. There was no significant difference in the rate of antidepressant prescribing between visits to Internists versus family/general practice (55.9% vs 48.0%; P = .42). Mental health counseling or psychotherapy was offered more often during visits to family/general practice physicians than to Internists (39.4% vs 14.0%; P = .07). CONCLUSIONS Visits for depression by elderly patients continue to take place in primary care settings to both family/general practice physicians and Internists. Interventions aimed at improving depression care in primary care should focus on both types of primary care physicians and emphasize improving rates of diagnosis and referral for counseling or psychotherapy as a viable treatment option.
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Affiliation(s)
- Jeffrey S Harman
- Department of Health Services Research, Management and Policy, College of Public Health and Health Professions, University of Florida, Gainesville, FL 32610-0195, USA.
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Crabtree BF, Miller WL, Tallia AF, Cohen DJ, DiCicco-Bloom B, McIlvain HE, Aita VA, Scott JG, Gregory PB, Stange KC, McDaniel RR. Delivery of clinical preventive services in family medicine offices. Ann Fam Med 2005; 3:430-5. [PMID: 16189059 PMCID: PMC1466921 DOI: 10.1370/afm.345] [Citation(s) in RCA: 84] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND This study aimed to elucidate how clinical preventive services are delivered in family practices and how this information might inform improvement efforts. METHODS We used a comparative case study design to observe clinical preventive service delivery in 18 purposefully selected Midwestern family medicine offices from 1997 to 1999. Medical records, observation of outpatient encounters, and patient exit cards were used to calculate practice-level rates of delivery of clinical preventive services. Field notes from direct observation of clinical encounters and prolonged observation of the practice and transcripts from in-depth interviews of practice staff and physicians were systematically examined to identify approaches to delivering clinical preventive services recommended by the US Preventive Services Task Force. RESULTS Practices developed individualized approaches for delivering clinical preventive services, with no one approach being successful across practices. Clinicians acknowledged a 3-fold mission of providing acute care, managing chronic problems, and prevention, but only some made prevention a priority. The clinical encounter was a central focus for preventive service delivery in all practices. Preventive services delivery rates often appeared to be influenced by competing demands within the clinical encounter (including between different preventive services), having a physician champion who prioritized prevention, and economic concerns. CONCLUSIONS Practice quality improvement efforts that assume there is an optimal approach for delivering clinical preventive services fail to account for practices' propensity to optimize care processes to meet local contexts. Interventions to enhance clinical preventive service delivery should be tailored to meet the local needs of practices and their patient populations.
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Affiliation(s)
- Benjamin F Crabtree
- Department of Family Medicine, UMDNJ-Robert Wood Johnson Medical School, New Brunswick, NJ 08873, USA.
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Abstract
PURPOSE This study provides basic information about the training and practices of licensed acupuncturists. METHODS Randomly selected licensed acupuncturists in Massachusetts and Washington state were interviewed and asked to record information on 20 consecutive patient visits. RESULTS Most acupuncturists in both states had 3 or 4 years of academic acupuncture training and had received additional "postgraduate" training as well. Acupuncturists treated a wide range of conditions, including musculoskeletal problems (usually back, neck, and shoulder) (33% in Massachusetts and 47% in Washington), general body symptoms (12% and 9%, respectively) such as fatigue, neurological problems (10% and 12%, respectively) (eg, headaches), and psychological complaints (10% and 8%, respectively) (especially anxiety and depression). Traditional Chinese medicine (TCM) was the predominant style of acupuncture used in both states (79% and 86%, respectively). Most visits included a traditional diagnostic assessment (more than 99%), regular body acupuncture (95% and 93%, respectively), and additional treatment modalities (79% and 77%, respectively). These included heat and lifestyle advice (66% and 65%, respectively), most commonly dietary advice and exercise recommendations. Chinese herbs were used in about one third of visits. Although most patients self-referred to acupuncture, about one half received concomitant care from a physician. Acupuncturists rarely communicated with the physicians of their patients who were providing care for the same problem. CONCLUSIONS This study contributes new information about acupuncturists and the care they provide that should be useful to clinicians interested in becoming more knowledgeable about complementary or alternative medical therapies available to their patients.
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Affiliation(s)
- Karen J Sherman
- Center for Health Studies, Group Health Cooperative, Seattle, WA 98101, USA.
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Griffin SJ, Kinmonth AL, Veltman MWM, Gillard S, Grant J, Stewart M. Effect on health-related outcomes of interventions to alter the interaction between patients and practitioners: a systematic review of trials. Ann Fam Med 2004; 2:595-608. [PMID: 15576546 PMCID: PMC1466743 DOI: 10.1370/afm.142] [Citation(s) in RCA: 397] [Impact Index Per Article: 19.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
PURPOSE We wanted to identify published randomized trials of interventions to alter the interaction between patients and practitioners, develop taxonomies of the interventions and outcomes, and assess the evidence that such interventions improve patients' health and well-being. METHODS Undertaking a systematic review of randomized trials, we sought trials in primary and secondary care with health-related outcomes, which we found by searching MEDLINE, HealthSTAR, and PsycINFO bibliographic databases through 1999. We also completed one round of manual citation searching. RESULTS Thirty-five trials were included. Most were set in primary care in North America. Trials were heterogeneous in populations, settings, interventions, and measures. Interventions frequently combined several poorly described elements. Explicit theoretical underpinning was rare, and only one study linked intervention through process to outcome measures. Health outcomes were rarely measured objectively (6 of 35), and only 4 trials with health outcomes met predefined quality criteria. Interventions frequently altered the process of interactions (significantly in 73%, 22 of 30 trials). Principal outcomes favored the intervention group in 74% of trials (26 of 35), reaching statistical significance in 14 (40%). Positive effects on health outcomes achieved statistical significance in 44% of trials (11 of 25); negative effects were uncommon (5 of 25, 20%). Simple approaches to increasing the participation of patients in the clinical encounter, such as providing practitioners with a note from patients about their concerns beforehand, showed promise, as did more complex programs providing specific information about disease and attention to emotion. Apparently similar interventions varied in effectiveness across studies. CONCLUSIONS Successful interactions between patients and their practitioners lie at the heart of medicine, yet there are few rigorous trials of well-specified interventions to inform best practice. Trial evidence suggests that a range of approaches can achieve changes in this interaction, and some show promise in improving patients' health. To advance knowledge further, we need to replicate promising studies using rigorous methods. These should include explicit theoretical frameworks designed to link effects on key communication and interaction characteristics through to effects on health outcomes.
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Affiliation(s)
- Simon J Griffin
- General Practice and Primary Care Research Unit, Department of Public Health and Primary Care, Institute of Public Health, University Forvie Site, Robinson Way, Cambridge, CB2 2SR, UK.
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