The End of the 15-20 Minute Primary Care Visit

Physician Intervention and Chinese Americans' Colorectal Cancer Screening

OBJECTIVE

We conducted a cluster-randomized trial evaluating an intervention that trained Chinese-American primary care physicians to increase their Chinese patients' colorectal cancer (CRC) screening.

METHODS

Twenty-five physicians (13 randomized to the intervention arm and 12 to the control arm) and 479 of their patients (aged 50-75 and nonadherent to CRC screening guidelines) were enrolled. The intervention, guided by Social Cognitive Theory, included a communication guide and 2 in-office training sessions to enhance physicians' efficacy in com- municating CRC screening with patients. Patients' CRC screening rates (trial outcome) and rating of physician communication before intervention and at 12-month follow-up were assessed. Intention-to-treat analysis for outcome evaluation was conducted.

RESULTS

Screening rates were slightly higher in the intervention vs. the control arm (24.4% vs. 17.7%, p = .24). In post hoc analyses, intervention arm patients who perceived better communication were more likely to be screened than those who did not (OR = 1.09, 95% CI: 1.03, 1.15). This relationship was not seen in the control arm.

CONCLUSIONS

This physician-focused intervention had small, non-significant effects in increasing Chinese patients' CRC screening rates. Physician communication appeared to explain intervention efficacy. More intensive interventions are needed to enhance Chinese patients' CRC screening.

Effectiveness of Shared Medical Appointments Targeting the Triple Aim Among Patients With Overweight, Obesity, or Diabetes

BACKGROUND

Obesity and diabetes are epidemic in the United States, with many treatment options having limited long-term efficacy. A possible effective medical management tool is the shared medical appointment (SMA), which offers an efficient and cost-effective approach to behavior change and aligns with the Triple Aim (reduce costs, improve population health, and improve patient care experience) set forth by the Institute for Healthcare Improvement.

OBJECTIVES

To assess the effectiveness of SMAs to achieve the Triple Aim and to improve the management of overweight/obesity or diabetes.

METHODS

Peer-reviewed literature from PubMed was searched by the keywords shared medical appointments, group medical appointment, and group medical visit, with no date restrictions and limited to English publications with sample sizes greater than or equal to 20.

RESULTS

Eight articles met inclusion criteria. The Triple Aim was not referenced in the studies, but most reported some combination of reduced costs, improved care, and improved outcomes or patient satisfaction.

CONCLUSIONS

Potential benefits of SMAs include improved patient outcomes and satisfaction. Osteopathic and, in particular, primary care medicine could likely benefit from moving toward greater adoption of SMAs; however, more randomized controlled trials are needed to assess their effectiveness with regard to the Triple Aim.

Ethical Implications of the Electronic Health Record: In the Service of the Patient

Electronic health records (EHRs) provide benefits for patients, physicians, and clinical teams, but also raise ethical questions. Navigating how to provide care in the digital age requires an assessment of the impact of the EHR on patient care and the patient-physician relationship. EHRs should facilitate patient care and, as an essential component of that care, support the patient-physician relationship. Billing, regulatory, research, documentation, and administrative functions determined by the operational requirements of health care systems, payers, and others have resulted in EHRs that are better able to satisfy such external functions than to ensure that patient care needs are met. The profession has a responsibility to identify and address this mismatch. This position paper by the American College of Physicians (ACP) Ethics, Professionalism and Human Rights Committee does not address EHR design, user variability, meaningful use, or coding requirements and other government and payer mandates per se; these issues are discussed in detail in ACP's Clinical Documentation policy. This paper focuses on EHRs and the patient-physician relationship and patient care; patient autonomy, privacy and confidentiality; and professionalism, clinical reasoning and training. It explores emerging ethical challenges and concerns for and raised by physicians across the professional lifespan, whose ongoing input is crucial to the development and use of information technology that truly serves patients.

Moderate mental illness as a predictor of chronic disease prevention and screening

Background

Primary care plays a pivotal role in the provision of both mental health care and chronic disease prevention and screening (CDPS). Unfortunately, moderate mental illness (MMI) is associated with poorer general health outcomes. Part of this burden of illness may be due to reduced CDPS uptake. The Building on the Existing Tools to Improve Chronic Disease Prevention in Primary Care (BETTER) trial recruited 777 participants ages 40–65 from 32 family practice panels, of whom 135 (18.2%) had elevated GAD scores, 118 (16.4%) had elevated PHQ scores, and 264 (34.0%) had electronic medical record (EMR)-documented MMI. We hypothesized that patients with screen-positive or chart-documented MMI are 1) eligible for more CDPS actions, and 2) able to complete a lower proportion of CDPS actions than patients unaffected by MMI.

Methods

This study was a secondary analysis of data from the BETTER trial. Participants were stratified by both EMR-documented MMI and screen-positive evidence of MMI (using the General Anxiety Disorders (GAD-7) and Patient Health Questionnaire (PHQ-9) instruments for anxiety and depression screening, respectively). The primary outcome was the proportion of CDPS actions for which the patient was eligible completed at follow-up, using a composite index.

Results

After adjusting for age, gender, and social support, patients with evidence of MMI had a lower composite index than patients without evidence of MMI (p < 0.05). The lower composite index is primarily due to higher eligibility for CDPS at baseline; ability to complete CDPS was not statistically different.

Conclusions

Patients affected by MMI are eligible for more CDPS actions than their unaffected counterparts. Although they are able to complete a similar number of CDPS actions, they are not able to eliminate their baseline CDPS gap. Primary care teams need to be aware of this increased CDPS eligibility for patients with MMI and ensure best practices in CDPS supports are available to this patient population. Further study is needed to determine the ideal suite of targeted supports.

Implementation and maintenance of patient navigation programs linking primary care with community-based health and social services: a scoping literature review

Background

Since the early 90s, patient navigation programs were introduced in the United States to address inequitable access to cancer care. Programs have since expanded internationally and in scope. The goals of patient navigation programs are to: a) link patients and families to primary care services, specialist care, and community-based health and social services (CBHSS); b) provide more holistic patient-centred care; and, c) identify and resolve patient barriers to care. This paper fills a gap in knowledge to reveal what is known about motivators and factors influencing implementation and maintenance of patient navigation programs in primary care that link patients to CBHSS. It also reports on outcomes from these studies to help identify gaps in research that can inform future studies.

Methods

This scoping literature review involved: i) electronic database searches; ii) a web site search; iii) a search of reference lists from literature reviews; and, iv) author follow up. It included papers from Canada, the United States, the United Kingdom, Australia, New Zealand, and/or Western Europe published between January 1990 and June 2013 if they discussed navigators or navigation programs in primary care settings that linked patients to CBHSS.

Results

Of 34 papers, most originated in the United States (n = 29) while the remainder were from the United Kingdom, Canada and Australia. Motivators for initiating navigation programs were to: a) improve delivery of health and social care services; b) support and manage specific health needs or specific population needs, and; c) improve quality of life and wellbeing of patients. Eleven factors were found to influence implementation and maintenance of these patient navigation programs. These factors closely aligned with the Diffusion of Innovation in Service Organizations model, thus providing a theoretical foundation to support them. Various positive outcomes were reported for patients, providers and navigators, as well as the health and social care system, although they need to be considered with caution since the majority of studies were descriptive.

Conclusions

This study contributes new knowledge that can inform the initiation and maintenance of primary care patient navigation programs that link patients with CBHSS. It also provides directions for future research.

Do Work Condition Interventions Affect Quality and Errors in Primary Care? Results from the Healthy Work Place Study

BACKGROUND

While primary care work conditions are associated with adverse clinician outcomes, little is known about the effect of work condition interventions on quality or safety.

DESIGN

A cluster randomized controlled trial of 34 clinics in the upper Midwest and New York City.

PARTICIPANTS

Primary care clinicians and their diabetic and hypertensive patients.

INTERVENTIONS

Quality improvement projects to improve communication between providers, workflow design, and chronic disease management. Intervention clinics received brief summaries of their clinician and patient outcome data at baseline.

MAIN MEASURES

We measured work conditions and clinician and patient outcomes both at baseline and 6-12 months post-intervention. Multilevel regression analyses assessed the impact of work condition changes on outcomes. Subgroup analyses assessed impact by intervention category.

KEY RESULTS

There were no significant differences in error reduction (19 % vs. 11 %, OR of improvement 1.84, 95 % CI 0.70, 4.82, p = 0.21) or quality of care improvement (19 % improved vs. 44 %, OR 0.62, 95 % CI 0.58, 1.21, p = 0.42) between intervention and control clinics. The conceptual model linking work conditions, provider outcomes, and error reduction showed significant relationships between work conditions and provider outcomes (p ≤ 0.001) and a trend toward a reduced error rate in providers with lower burnout (OR 1.44, 95 % CI 0.94, 2.23, p = 0.09).

LIMITATIONS

Few quality metrics, short time span, fewer clinicians recruited than anticipated.

CONCLUSIONS

Work-life interventions improving clinician satisfaction and well-being do not necessarily reduce errors or improve quality. Longer, more focused interventions may be needed to produce meaningful improvements in patient care.

CLINICAL TRIAL REGISTRATION NUMBER

ClinicalTrials.gov # NCT02542995.

Worklife and Wellness in Academic General Internal Medicine: Results from a National Survey

BACKGROUND

General internal medicine (GIM) careers are increasingly viewed as challenging and unsustainable.

OBJECTIVE

We aimed to assess academic GIM worklife and determine remediable predictors of stress and burnout.

DESIGN

We conducted an email survey.

PARTICIPANTS

Physicians, nurse practitioners, and physician assistants in 15 GIM divisions participated.

MAIN MEASURES

A ten-item survey queried stress, burnout, and work conditions such as electronic medical record (EMR) challenges. An open-ended question assessed stressors and solutions. Results were categorized into burnout, high stress, high control, chaos, good teamwork, high values alignment, documentation time pressure, and excessive home EMR use. Frequencies were determined for national data, Veterans Affairs (VA) versus civilian populations, and hospitalist versus ambulatory roles. A General Linear Mixed Model (GLMM) evaluated associations with burnout. A formal content analysis was performed for open-ended question responses.

KEY RESULTS

Of 1235 clinicians sampled, 579 responded (47 %). High stress was present in 67 %, with 38 % burned out (burnout range 10-56 % by division). Half of respondents had low work control, 60 % reported high documentation time pressure, half described too much home EMR time, and most reported very busy or chaotic workplaces. Two-thirds felt aligned with departmental leaders' values, and three-quarters were satisfied with teamwork. Burnout was associated with high stress, low work control, and low values alignment with leaders (all p < 0.001). The 45 VA faculty had less burnout than civilian counterparts (17 % vs. 40 %, p < 0.05). Hospitalists described better teamwork than ambulatory clinicians and fewer hospitalists noted documentation time pressure (both p < 0.001). Key themes from the qualitative analysis were short visits, insufficient support staff, a Relative Value Unit mentality, documentation time pressure, and undervaluing education.

CONCLUSIONS

While GIM divisions overall demonstrate high stress and burnout, division rates vary widely. Sustainability efforts within GIM could focus on visit length, staff support, schedule control, clinic chaos, and EMR stress.