Disentangling the Linkage of Primary Care Features to Patient Outcomes: A Review of Current Literature, Data Sources, and Measurement Needs

Quality of primary health care for chronic diseases in low-resource settings: Evidence from a comprehensive study in rural China

BACKGROUND

There is a paucity of evidence regarding the definition of the quality of primary health care (PHC) in China. This study aims to evaluate the PHC quality for chronic diseases in rural areas based on a modified conceptual framework tailored to the context of rural China.

METHODS

This comprehensive study, involving a patient survey, a provider survey and chart abstraction, and second-hand registered data, was set in three low-resource counties in rural China from 2021 to 2022. Rural patients with hypertension or type 2 diabetes, and health care workers providing care on hypertension or diabetes were involved. The modified PHC quality framework encompasses three core domains: a competent PHC system (comprehensiveness, accessibility, continuity, and coordination), effective clinical care (assessment, diagnosis, treatment, disease management, and provider competence), and positive user experience (information sharing, shared decision-making, respect for patient's preferences, and family-centeredness). Standardized PHC quality score was generated by arithmetic means or Rasch models of Item Response Theory.

RESULTS

This study included 1355 patients, 333 health care providers and 2203 medical records. Ranging from 0 (the worst) to 1 (the best), the average quality score for the PHC system was 0.718, with 0.887 for comprehensiveness, 0.781 for accessibility, 0.489 for continuity, and 0.714 for coordination. For clinical care, average quality was 0.773 for disease assessment, 0.768 for diagnosis, 0.677 for treatment, 0.777 for disease management, and 0.314 for provider competence. The average quality for user experience was 0.727, with 0.933 for information sharing, 0.657 for shared decision-making, 0.936 for respect for patients' preferences, and 0.382 for family-centeredness. The differences in quality among population subgroups, although statistically significant, were small.

CONCLUSION

The PHC quality in rural China has shown strengths and limitations. We identified large gaps in continuity of care, treatment, provider competence, family-centeredness, and shared decision-making. Policymakers should invest more effort in addressing these gaps to improve PHC quality.

Current Practices in Clinical Supervision in Primary Care

The purpose of this study was to examine current clinical supervision practices within primary care settings. We used a descriptive survey design, which blends quantitative and qualitative data, and examined the current state of clinical supervision practices and approaches in primary care and the type of training the behavioral health consultants received to provide supervision to pre-licensure level behavioral health trainees. Ninety-four participants completed the survey in 2022. Seventy-one percent of respondents felt they had adequate training to be an effective integrated behavioral health (IBH) supervisor; however, most training came from sources, such as workshops, continuing education, or supervision of supervision. Further efforts to establish universal competencies and formal training programs are needed to meet the growing need for IBH services in primary care.

Factors that influence scope-of-practice decisions of early-career family physicians: Focus group study in Canada

OBJECTIVE

To explore perceptions of early-career family physicians on the personal, educational, organizational, community, and system factors that had influenced their scope-of-practice decisions and to compare the similarities and differences among these factors across all 13 Canadian jurisdictions.

DESIGN

Qualitative descriptive study.

SETTING

Canada.

PARTICIPANTS

Fifty-nine early-career family physicians who were 2 to 5 years into independent practice.

METHODS

Data were collected using focus groups and were analyzed using deductive and inductive analysis techniques to identify patterns in the data within and across jurisdictions.

MAIN FINDINGS

Participants across all jurisdictions highlighted that personal factors (ie, interest, work-life balance and family life, financial considerations, and self-perceived competence and confidence) were most influential on scope-of-practice decisions. Educational (ie, exposure during training, mentorship), organizational (ie, collegial support), community (ie, needs), and system (ie, payment models, funding for team-based care, governance) factors also influenced decisions about scope of practice. Experiences were similar across all jurisdictions for personal factors. Differences in experiences were reported across jurisdictions for educational, organizational, community, and system factors.

CONCLUSION

Decisions about scope of practice by early-career family physicians are highly influenced by personal factors followed by organizational, educational, community, and system factors. These findings suggest numerous strategies are needed to increase individuals' interest in providing comprehensive care in Canada. Educators should cultivate interest in comprehensive care among learners, strategically recruit trainees, provide targeted exposure and experiences, ensure competence and confidence are evaluated throughout and at the end of training, and introduce formal mentorship programs. Policy-makers should invest in the spread of effective team models and alternative payment models. Together, these strategies could broaden the scopes of practice of family physicians and their capacity to deliver accessible and comprehensive care to Canadians.

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

OBJECTIVES

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

DESIGN

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

SETTING

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

PARTICIPANTS

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

OUTCOME MEASURES

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

SECONDARY OUTCOME MEASURES

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

RESULTS

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

CONCLUSIONS

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

How did general practices organize care during the COVID-19 pandemic: the protocol of the cross-sectional PRICOV-19 study in 38 countries

BACKGROUND

General practitioners (GPs) play a crucial role in the fight against the COVID-19 pandemic as the first point of contact for possibly infected patients and are responsible for short and long-term follow-up care of the majority of COVID-19 patients. Nonetheless, they experience many barriers to fulfilling this role. The PRICOV-19 study investigates how GP practices in 38 countries are organized during the COVID-19 pandemic to guarantee safe, effective, patient-centered, and equitable care. Also, the shift in roles and tasks and the wellbeing of staff members is researched. Finally, PRICOV-19 aims to study the association with practice- and health care system characteristics. It is expected that both characteristics of the GP practice and health care system features are associated with how GP practices can cope with these challenges. This paper describes the protocol of the study.

METHODS

Using a cross-sectional design, data are collected through an online questionnaire sent to GP practices in 37 European countries and Israel. The questionnaire is developed in multiple phases, including a pilot study in Belgium. The final version includes 53 items divided into six sections: patient flow (including appointments, triage, and management for routine care); infection prevention; information processing; communication; collaboration and self-care; and practice and participant characteristics. In the countries where data collection is already finished, between 13 and 636 GP practices per country participated in the study. Questionnaire data are linked with OECD and HSMR data regarding national policy responses to the pandemic and analyzed using multilevel models considering the system- and practice-level.

DISCUSSION

To the best of our knowledge, the PRICOV-19 study is the largest and most comprehensive study that examines how GP practices function during the COVID-19 pandemic. Its results can significantly contribute to better preparedness of primary health care systems across Europe for future major outbreaks of infectious diseases.

A Health Care Value Framework for Physical Therapy Primary Health Care Organizations

BACKGROUND AND OBJECTIVE

To develop a health care value framework for physical therapy primary health care organizations including a definition.

METHOD

A scoping review was performed. First, relevant studies were identified in 4 databases (n = 74). Independent reviewers selected eligible studies. Numerical and thematic analyses were performed to draft a preliminary framework including a definition. Next, the feasibility of the framework and definition was explored by physical therapy primary health care organization experts.

RESULTS

Numerical and thematic data on health care quality and context-specific performance resulted in a health care value framework for physical therapy primary health care organizations-including a definition of health care value, namely "to continuously attain physical therapy primary health care organization-centered outcomes in coherence with patient- and stakeholder-centered outcomes, leveraged by an organization's capacity for change."

CONCLUSION

Prior literature mainly discussed health care quality and context-specific performance for primary health care organizations separately. The current study met the need for a value-based framework, feasible for physical therapy primary health care organizations, which are for a large part micro or small. It also solves the omissions of incoherent literature and existing frameworks on continuous health care quality and context-specific performance. Future research is recommended on longitudinal exploration of the HV (health care value) framework.

Practical recommendations for timely, accurate diagnosis of symptomatic Alzheimer's disease (MCI and dementia) in primary care: a review and synthesis

The critical role of primary care clinicians (PCCs) in Alzheimer's disease (AD) prevention, diagnosis and management must evolve as new treatment paradigms and disease-modifying therapies (DMTs) emerge. Our understanding of AD has grown substantially: no longer conceptualized as a late-in-life syndrome of cognitive and functional impairments, we now recognize that AD pathology builds silently for decades before cognitive impairment is detectable. Clinically, AD first manifests subtly as mild cognitive impairment (MCI) due to AD before progressing to dementia. Emerging optimism for improved outcomes in AD stems from a focus on preventive interventions in midlife and timely, biomarker-confirmed diagnosis at early signs of cognitive deficits (i.e. MCI due to AD and mild AD dementia). A timely AD diagnosis is particularly important for optimizing patient care and enabling the appropriate use of anticipated DMTs. An accelerating challenge for PCCs and AD specialists will be to respond to innovations in diagnostics and therapy for AD in a system that is not currently well positioned to do so. To overcome these challenges, PCCs and AD specialists must collaborate closely to navigate and optimize dynamically evolving AD care in the face of new opportunities. In the spirit of this collaboration, we summarize here some prominent and influential models that inform our current understanding of AD. We also advocate for timely and accurate (i.e. biomarker-defined) diagnosis of early AD. In doing so, we consider evolving issues related to prevention, detecting emerging cognitive impairment and the role of biomarkers in the clinic.

The Changing Landscape Of Primary Care: Effects Of The ACA And Other Efforts Over The Past Decade

Providing high-quality primary care is key to improving health care in the United States. The Affordable Care Act sharpened the emerging focus on primary care as a critical lever to use in improving health care delivery, lowering costs, and improving the quality of care. We describe primary care delivery system reform models that were developed and tested over the past decade by the Center for Medicare and Medicaid Innovation-which was created by the Affordable Care Act-and reflect on key lessons and remaining challenges. Considerable progress has been made in understanding how to implement and support different approaches to improving primary care delivery in that decade, though evaluations showed little progress in spending or quality outcomes. This may be because none of the models was able to test substantial increases in primary care payment or strong incentives for other providers to coordinate with primary care to reduce costs and improve quality.

Assessing the Longitudinal Impact of Physician-Patient Relationship on Functional Health

PURPOSE

Access to a usual source of care is associated with improved health outcomes, but research on how the physician-patient relationship affects a patient's health, particularly long-term, is limited. The aim of this study was to investigate the longitudinal effect of changes in the physician-patient relationship on functional health.

METHODS

We conducted a prospective cohort study using the Medical Expenditure Panel Survey (MEPS, 2015-2016). The outcome was 1-year change in functional health (12-Item Short-Form Survey). The predictors were quality of physician-patient relationship, and changes in this relationship, operationalized with the MEPS Primary Care (MEPS-PC) Relationship subscale, a composite measure with preliminary evidence of reliability and validity. Confounders included age, sex, race/ethnicity, educational attainment, insurance status, US region, and multimorbidity. We conducted analyses with survey-weighted, covariate-adjusted, predicted marginal means, used to calculate Cohen effect estimates. We tested differences in trajectories with multiple pairwise comparisons with Tukey contrasts.

RESULTS

Improved physician-patient relationships were associated with improved functional health, whereas worsened physician-patient relationships were associated with worsened functional health, with 1-year effect estimates ranging from 0.05 (95% CI, 0-0.10) to 0.08 (95% CI, 0.02-0.13) compared with -0.16 (95% CI, -0.35 to -0.03) to -0.33 (95% CI, -0.47 to -0.02), respectively.

CONCLUSION

The quality of the physician-patient relationship is positively associated with functional health. These findings could inform health care strategies and health policy aimed at improving patient-centered health outcomes.

Delivery of essential surgery by family physicians

Primary health care provides the framework for delivering the socially-informed, comprehensive and patient-centred care underlying robust health-care systems and is, therefore, central to achieving universal health coverage. Family physicians are best placed to embody primary health care’s dual focus on community and population health because they are often employed in rural or district hospitals with limited human resources, particularly a lack of specialists. Here we want to illustrate how additional training for family physicians, the key clinicians in primary care, can play a critical role in reducing disparities in access to surgical, obstetric and anaesthesia care in low- and middle-income countries and in rural or remote settings. Examples are given of how training programmes can be developed in low-resource settings to equip family physicians with life-saving surgical skills and of how family physicians in high-income countries can be trained in the surgical skills essential for working overseas in low-income settings. Policy-makers should promote surgical practice among family physicians by supporting family medicine programmes that include additional surgical skills training and by expanding opportunities and incentives for family physicians to serve in rural areas. Moreover, national surgical plans should include a primary health care strategy for surgical care and, globally, family physicians should be considered in discussions of surgical care. Finally, surgeons, anaesthesiologists, obstetricians and family physicians should be encouraged to collaborate in ensuring that all patients, regardless of place of residence, receive safe and timely surgical care.

The How Matters: How Primary Care Provider Communication With Team Relates to Patients' Disease Management

BACKGROUND

Investigating primary care provider (PCP)-team communication can provide insight into how colleagues work together to become high-functioning teams more able to address an increasingly complex set of tasks associated with chronic disease management.

OBJECTIVE

To assess how PCP communication with their care team relates to patients' health.

RESEARCH DESIGN

Longitudinal study of how 3 aspects of PCP-care team communication-participation, time spent listening, and uninterrupted speaking length-relate to disease management of patients with hypertension or diabetes, and the effect of these team communication behaviors on PCP-patient communication as a pathway by which this relationship might exist. We used multilevel regression models.

SUBJECTS

Twenty-seven PCPs and 98 team members, and 18,067 patients with hypertension and 8354 patients with diabetes affiliated with a federally qualified health center with 12 practice sites.

MEASURES

Primary data on communication collected using sociometric sensors worn by PCPs and team members, patient-PCP communication data collected with surveys, and patient health, PCP and patient characteristics extracted from electronic records.

RESULTS

PCPs participated in 75% of care team conversations, spent 56% of conversation time listening, and had an average uninterrupted speaking length of 2.42 seconds. PCP participation, listening, and length of uninterrupted speaking time were associated with significantly higher odds that their patients had controlled hypertension and diabetes and improvements in disease control over time. PCP-patient communication mediates this relationship.

CONCLUSIONS

PCP-team communication is associated with patient health management. How team members speak with one another may be as important as the content of their communication.

A Novel Approach to Postpartum Contraception Provision Combined with Infant Care: A Randomized, Controlled Trial

BACKGROUND

Unintended pregnancy among women with short interpregnancy intervals remains common. Women's attendance at the 4- to 6-week postpartum visit, when contraception provision often occurs, is low, whereas their attendance at well-baby visits is high. We aimed to evaluate if offering co-located contraceptive services to mothers at well-baby visits increases use of long-acting reversible contraception (LARC) at 5 months postpartum compared with usual care in a randomized, controlled trial.

METHODS

Women with infants aged 4.5 months or younger who were not using a LARC method and had not undergone sterilization were eligible. Generalized linear models were used to estimate risk ratios. Likability and satisfaction of the contraception visit were assessed.

RESULTS

Between January 2015 and January 2017, 446 women were randomized. LARC use at 5 months was 19.1% and 20.9% for the intervention and control groups, respectively, and was not significantly different after controlling for weeks postpartum (risk ratio, 0.85; 95% confidence interval, 0.59-1.23). Uptake of the co-located visit was low (17.7%), but the concept was liked; insufficient time to stay for the visit was the biggest barrier to uptake. Women who accepted the visit were more likely to use a LARC method at 5 months compared with women in the control group (risk ratio, 1.97; 95% confidence interval, 1.26-3.07).

CONCLUSIONS

Women perceived co-located care favorably and LARC use was higher among those who completed a visit; however, uptake was low for reasons including inability to stay after the infant visit. Intervention effects were possibly diluted. Future research should test a version of this intervention designed to overcome barriers that participants reported.

Integrating health care in Australia: a qualitative evaluation

BACKGROUND

With aging populations, a growing prevalence of chronic illnesses, higher expectations for quality care and rising costs within limited health budgets, integration of healthcare is seen as a solution to these challenges. Integrated healthcare aims to overcome barriers between primary and secondary care and other disconnected patient services to improve access, continuity and quality of care. Many people in Australia are admitted to hospital for chronic illnesses that could be prevented or managed in the community. Western Sydney has high rates of diabetes, heart and respiratory diseases and the NSW State Ministry of Health has implemented key strategies through the Western Sydney Integrated Care Program (WSICP) to enhance primary care and the outcomes and experiences of patients with these illnesses.

METHODS

We aimed to investigate the WSICP's effectiveness through a qualitative evaluation focused on the 10 WSICP strategies using a framework analysis. We administered 125 in-depth interviews in two rounds over 12 months with 83 participants including patients and their carers, care facilitators, hospital specialists and nurses, allied health professionals, general practitioners (GPs) and primary care nurses, and program managers. Most participants (71%) were interviewed twice. We analysed data within a framework describing how strategies were implemented and used, the experiences around these, their perceived value, facilitators and barriers, and participant-identified suggestions for improvement.

RESULTS

Care facilitators helped patients access services within the hospital and in primary care and connected general practices with hospital specialists and services. Rapid access and stabilisation clinics with their patient hotlines assisted patients and carers to self-manage chronic illness while connecting GPs to specialists through the GP support-line. Action plans from the hospital informed GPs and their shared care plans which could be accessed by other community health professionals and patients. HealthPathways provided GPs with local, evidence-based guidelines for managing patients. Difficulties persisted in effective widespread access to shared records and electronic communication across sectors.

CONCLUSIONS

The combined WSICP strategies improved patient and carer experience of healthcare and capacity of GPs to provide care in the community. Information sharing required longer-term investment and support, though benefits were evident by the end of our research.

Specialty and Lifestyle Preference Changes during Medical School

PURPOSE

Medical student specialty choices have significant downstream effects on the availability of physicians and, ultimately, the effectiveness of health systems. This study investigated how medical student specialty preferences change over time in relation to their demographics and lifestyle preferences.

METHOD

Students from ten medical schools were surveyed at matriculation (2012) and graduation (2016). The two surveys included questions about specialty and lifestyle preferences, demographics, educational background, and indebtedness. Student data from 2012 to 2016 were paired together and grouped into those whose specialty preferences remained constant or switched.

RESULTS

Response rates in 2012 and 2016 were 65% (997/1530) and 50% (788/1575), respectively. Fourth-year students ranked "enjoying the type of work I am doing" as less important to a good physician lifestyle than did first-year students (from 59.6 to 39.7%). The lifestyle factors "having control of work schedule" and "having enough time off work" were ranked as more important to fourth-year students than first-year students (from 15.6 to 18.2% and 14.8 to 31.9%, respectively). The paired dataset included 19% of eligible students (237/1226). Demographic and lifestyle factors were not significantly associated with specialty preference switching. Additionally, no significant association existed between changing lifestyle preferences and switching specialty preference (p = 0.85).

CONCLUSIONS

During the course of medical school, lifestyle preferences became more focused on day-to-day factors and less on deeper motivational factors. Neither demographics nor lifestyle preferences appear to relate to a student's decision to switch specialty preference during medical school. These findings represent an important step in uncovering causes of specialty preference trends.

Communicating acute coronary syndrome risk to women in primary care: A scoping review of the literature

OBJECTIVES

Delay from symptom onset to hospital arrival drives poor outcomes in acute coronary syndrome (ACS), particularly for women. Primary care clinicians can discuss ACS with high-risk women, potentially reducing delay. We conducted a scoping review to assess what is known about ACS risk communication to women in primary care.

METHODS

We used Arksey and O'Malley's framework. The PubMed, CINAHL, PsycINFO, and Embase databases were searched for relevant articles from inception through September, 2018. No restrictions on study methodology were applied. At least two reviewers assessed each article. Articles addressing risk communication, coronary heart disease, and ACS, related to primary care settings, and including women were retained.

RESULTS

Eleven articles met inclusion criteria. Cardiovascular disease (CVD) risk communication is common in primary care; however, ACS symptoms are rarely discussed. Structured risk calculators are used to frame discussions. Communication styles include patient-centered discussions, paternalistic orders, and "scare tactics;" no single style is more effective. Analysis of gender differences in risk communication is extremely limited.

CONCLUSION

There is scant evidence that primary care clinicians communicate effectively about ACS risk, symptoms, and appropriate symptom response.

PRACTICE IMPLICATIONS

Interventions are needed to improve communication about ACS to at-risk women in the primary care setting.

Validating the New Primary Care Measure in the Medical Expenditure Panel Survey

BACKGROUND

The advancement of primary care research requires reliable and validated measures that capture primary care processes embedded within nationally representative datasets.

OBJECTIVE

The objective of this study was to assess the validity of a newly developed measure of primary care processes [Medical Expenditure Panel Survey (MEPS)-PC] with preliminary evidence of moderate to excellent reliability.

STUDY DESIGN

A retrospective cohort study of community-dwelling adults with history of office-based provider visit/s using the MEPS (2013-2014).

METHODS

The 3 MEPS-PC subscales (Relationship, Comprehensiveness, and Health Promotion) were tested for construct validity against known measures of primary care: Usual Source of Care, Known Provider, and Family-Usual Source of Care. Concurrent and predictive logistic regression analyses were calculated and compared with a priori hypotheses for direction and strength of association.

RESULTS

For concurrent validity, all odds ratio estimates conformed with hypotheses, with 91% displaying statistical significance. For predictive validity, all estimates were in the direction of hypotheses, with 92% displaying statistically significant results. Although Relationship and Health Promotion subscales conformed uniformly with hypotheses, the Comprehensiveness subscale yielded significant results in 60% of bivariate odds ratio estimates (P<0.05).

CONCLUSION

The MEPS-PC composite measures display modest to strong preliminary evidence of concurrent and predictive validity relative to known indicators of primary care.

IMPLICATIONS FOR POLICY AND PRACTICE

The MEPS-PC composite measures display preliminary evidence of concurrent and predictive construct validity, and it may be useful to researchers investigating primary care processes and complexities in the health care environment.

Citizen Preferences for Primary Health Care reform in Greece

BACKGROUND

The Greek National Health System is currently pursuing the strengthening of Primary Health Care (PHC). Citizen preferences for healthcare service utilization, their views on structural reform of the current system, and the profiling of those in favor of PHC are essential in planning a reform that respects citizens' needs. However, data on this topic in the country are scarce. The present study maps citizen preferences for health care reform in the primary care sector in Greece.

METHODS

In March 2017, a sample of 1,002 citizens were surveyed by telephone. The survey was repeated with a different sample of 1,001 persons in October 2017. Both samples were defined via a random multistage selection process using a quota for the municipality of residence, sex, and age. Responders were asked to rate their satisfaction with the existing healthcare system and to rank their preferences as to the most important elements of future structural reform. Barriers to accessing healthcare services and in the implementation of structural reform as well as actual healthcare services utilization were also recorded. A logistic regression model was used to identify sample characteristics independently associated with the most requested reform.

RESULTS

Citizens preferred to visit physicians -as outpatients- in their private practices (50.5 % in March and 44 % in October) rather than in public health services (17.8 % and 18 %, respectively). For 86.9 % and 85.6 %, respectively, structural reform of the current health system was considered "very" or "extremely necessary". The introduction of family physicians in the system was the most requested reform (48 % and 49.4 %, respectively). Citizens in older age groups were more likely to request the implementation of family physicians (25-39 years old: OR: 2.14, 95 % CI: 1.36-3.37; 40-54 years old: OR: 2.89, 95 % CI: 1.85-4.52; 55-64 years old: OR: 3.62, 95 % CI: 2.27-5.78; and over 65 years old: OR: 3.32, 95 % CI: 2.10-5.26). Male responders were 23 % less likely (OR: 0.77, 95 % CI: 0.63-0.93) to be in favor of this reform, after controlling for the other variables in the model.

CONCLUSIONS

Both survey streams reveal the growing demand for structural reform in the current healthcare system. Strengthening PHC is the most requested reform. Older and female citizens were more likely to be in favor of this reform. Integrating the private sector in developing a comprehensive PHC system, enhancing existing public health services, and increasing public awareness of the advantages of PHC should be considered critical elements of a high-quality PHC system. HIPPOKRATIA 2019, 23(3): 111-117.

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

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

Hospitalizations for Ambulatory Care-Sensitive Conditions among Children with Chronic and Complex Diseases

OBJECTIVE

To evaluate ambulatory-care sensitive (ACS) hospitalizations for children with noncomplex chronic diseases (NC-CD) and children with medical complexity (CMC), and identify associations with ambulatory care characteristics. Although ACS hospitalizations are potentially preventable in general populations, the specific ambulatory care predictors and influence of medical complexity on them is poorly understood.

STUDY DESIGN

Retrospective cohort study of NC-CD and CMC hospitalizations at a children's hospital during 2007-2014, excluding labor/delivery and children over 21 years. Pediatric medical complexity algorithm identified NC-CD or CMC. ACS hospitalizations were identified using Agency for Healthcare Research and Quality indicator definitions. Demographic and ambulatory care characteristics were compared between ACS and non-ACS hospitalizations with logistic regression clustered by patient. Measures of ambulatory care during 2 years before admission were explored with 20% random sample of general pediatrics discharges.

RESULTS

Among 4035 children with NC-CD, 14.6% of 4926 hospitalizations were ACS hospitalizations. Among 5084 CMC, 5.3% of 14 390 discharges were ACS hospitalizations. Among NC-CD discharges, ACS hospitalizations were more likely with no prior-year outpatient visits (OR 1.4, 95% CI 1.1-1.7) and less likely with timely well checks (OR 0.8, 95% CI 0.6-0.9) and phone encounters in the month before admission (OR 0.5, 95% CI 0.2-1.0). Among CMC discharges, the only association observed was with provider continuity (OR 0.3, 95% CI 0.1- 1.0).

CONCLUSIONS

Provider continuity may be associated with fewer CMC ACS hospitalizations, however, measures of ambulatory care were more consistently associated with ACS hospitalizations for NC-CD. CMC may need more precise ACS hospitalization definitions.

Frequent emergency department visitors are frequent primary care visitors and report unmet primary care needs

A small percentage of emergency department (ED) visitors account for a disproportionate portion of ED visits. Little is known about their relationships with their primary care providers (PCPs). This study compares frequent and infrequent ED visitors' primary care utilization and perceptions of primary care access, continuity, and connectedness and examines primary care utilization and perceptions as predictors of ED use. Data were obtained from 2 cross-sectional studies of psychosocial predictors of high levels of utilization at 2 urban hospitals. Data included age, sex, race/ethnicity, number and type of chronic conditions, self-rated health, and number of primary care and ED visits in the previous 12 months. Participants also answered 8 primary care access, continuity, and connectedness items. Participants with frequent ED visits (N = 70) were younger (43.24 vs 48.34, P = .020), more likely to be African American (61.4% vs 41.8%, P < .001), had a significant chronic illness burden (5.83 vs 2.83 chronic conditions, P < .001), and were more likely to report fair or poor health (65.7% vs 50.4%, P = .009). Frequent ED users were as likely as infrequent users to have a usual source of care, and reported similar primary care access, relationship length, and likelihood of provider knowing them well. Although making twice as many primary care visits, these participants were less likely to report that they could get what they need from their PCP (76.12% vs 92.53%, P < .001). Despite similar primary care access and continuity, frequent ED visitors are less likely to report that they get what they need from their PCPs. Further research should investigate their needs and how primary care can best provide high-value care to this complex population.

Physician Service Attribution Methods for Examining Provision of Low-Value Care

Objectives:

There has been significant research on provider attribution for quality and cost. Low-value care is an area of heightened focus, with little of the focus being on measurement; a key methodological decision is how to attribute delivered services and procedures. We illustrate the difference in relative and absolute physician- and panel-attributed services and procedures using overuse in cervical cancer screening.

Study Design:

A retrospective, cross-sectional study in an integrated health care system.

Methods:

We used 2013 physician-level data from Group Health Cooperative to calculate two utilization attributions: (1) panel attribution with the procedure assigned to the physician’s predetermined panel, regardless of who performed the procedure; and (2) physician attribution with the procedure assigned to the performing physician. We calculated the percentage of low-value cervical cancer screening tests and ranked physicians within the clinic using the two utilization attribution methods.

Results:

The percentage of low-value cervical cancer screening varied substantially between physician and panel attributions. Across the whole delivery system, median panel- and physician-attributed percentages were 15 percent and 10 percent, respectively. Among sampled clinics, panel-attributed percentages ranged between 10 percent and 17 percent, and physician-attributed percentages ranged between 9 percent and 13 percent. Within a clinic, median panel-attributed screening percentage was 17 percent (range 0 percent–27 percent) and physician-attributed percentage was 11 percent (range 0 percent–24 percent); physician rank varied by attribution method.

Conclusions:

The attribution method is an important methodological decision when developing low-value care measures since measures may ultimately have an impact on national benchmarking and quality scores. Cross-organizational dialogue and transparency in low-value care measurement will become increasingly important for all stakeholders.

Interconception Care for Mothers During Well-Child Visits With Family Physicians: An IMPLICIT Network Study

PURPOSE

Interconception care (ICC) is recommended to improve birth outcomes by targeting maternal risk factors, but little is known about its implementation. We evaluated the frequency and nature of ICC delivered to mothers at well-child visits and maternal receptivity to these practices.

METHODS

We surveyed a convenience sample of mothers accompanying their child to well-child visits at family medicine academic practices in the IMPLICIT (Interventions to Minimize Preterm and Low Birth Weight Infants Through Continuous Improvement Techniques) Network. Health history, behaviors, and the frequency of the child's physician addressing maternal depression, tobacco use, family planning, and folic acid supplementation were assessed, along with maternal receptivity to advice.

RESULTS

Three-quarters of the 658 respondents shared a medical home with their child. Overall, 17% of respondents reported a previous preterm birth, 19% reported a history of depression, 25% were smoking, 26% were not using contraception, and 58% were not taking folic acid. Regarding advice, 80% of mothers who smoked were counseled to quit, 59% reported depression screening, 71% discussed contraception, and 44% discussed folic acid. Screening for depression and family planning was more likely when the mother and child shared a medical home (P <.05). Most mothers, nearly 95%, were willing to accept health advice from their child's physician regardless of whether a medical home was shared (P >.05).

CONCLUSIONS

Family physicians provide key elements of ICC at well-child visits, and mothers are highly receptive to advice from their child's physician even if they receive primary care elsewhere. Routine integration of ICC at these visits may provide an opportunity to reduce maternal risk factors for adverse subsequent birth outcomes.