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Gaffney A, Himmelstein DU, Dickman S, McCormick D, Cai C, Woolhandler S. Trends and Disparities in the Distribution of Outpatient Physicians' Annual Face Time with Patients, 1979-2018. J Gen Intern Med 2023; 38:434-441. [PMID: 35668239 PMCID: PMC9905461 DOI: 10.1007/s11606-022-07688-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 05/25/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Physician time is a valuable yet finite resource. Whether such time is apportioned equitably among population subgroups, and how the provision of that time has changed in recent decades, is unclear. OBJECTIVE To investigate trends and racial/ethnic disparities in the receipt of annual face time with physicians in the USA. DESIGN Repeated cross-sectional. SETTING National Ambulatory Medical Care Survey, 1979-1981, 1985, 1989-2016, 2018. PARTICIPANTS Office-based physicians. MEASURES Exposures included race/ethnicity (White, Black, and Hispanic); age (<18, 18-64, and 65+); and survey year. Our main outcome was patients' annual visit face time with a physician; secondary outcomes include annual visit rates and mean visit duration. RESULTS Our sample included n=1,108,835 patient visits. From 1979 to 2018, annual outpatient physician face time per capita rose from 40.0 to 60.4 min, an increase driven by a rise in mean visit length and not in the number of visits. However, since 2005, mean annual face time with a primary care physician has fallen, a decline offset by rising time with specialists. Face time provided per physician changed little given growth in the physician workforce. A racial/ethnic gap in physician visit time present at the beginning of the study period widened over time. In 2014-2018, White individuals received 70.0 min of physician face time per year, vs. 52.4 among Black and 53.0 among Hispanic individuals. This disparity was driven by differences in visit rates, not mean visit length, and in the provision of specialist but not primary care. LIMITATION Self-reported visit length. CONCLUSION Americans' annual face time with office-based physicians rose for three decades after 1979, yet is still allocated inequitably, particularly by specialists; meanwhile, time spent by Americans with primary care physicians is falling. These trends and disparities may adversely affect patient outcomes. Policy change is needed to assure better allocation of this resource.
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Affiliation(s)
- Adam Gaffney
- Harvard Medical School, Boston, MA USA
- Department of Medicine, Cambridge Health Alliance, Cambridge, MA USA
| | - David U. Himmelstein
- Harvard Medical School, Boston, MA USA
- Department of Medicine, Cambridge Health Alliance, Cambridge, MA USA
- Hunter College, City University of New York, New York, NY USA
- Public Citizen Health Research Group, Washington, DC USA
| | | | - Danny McCormick
- Harvard Medical School, Boston, MA USA
- Department of Medicine, Cambridge Health Alliance, Cambridge, MA USA
| | | | - Steffie Woolhandler
- Harvard Medical School, Boston, MA USA
- Department of Medicine, Cambridge Health Alliance, Cambridge, MA USA
- Hunter College, City University of New York, New York, NY USA
- Public Citizen Health Research Group, Washington, DC USA
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Morgan K, Lewis J, Hawkins J, Moore G. From a research trial to routine practice: stakeholders' perceptions and experiences of referrals to the National Exercise Referral Scheme (NERS) in Wales. BMC Health Serv Res 2021; 21:1232. [PMID: 34774040 PMCID: PMC8590360 DOI: 10.1186/s12913-021-07266-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Accepted: 10/29/2021] [Indexed: 11/29/2022] Open
Abstract
Background Over ten years on from a randomised controlled trial and subsequent national roll-out, the National Exercise Referral Scheme (NERS) continues to be routinely delivered in primary care across Wales, UK. Few studies have revisited effective interventions years into their delivery in routine practice to understand how implementation, and perceived effects, have been maintained over time. This study explores perceptions and experiences of referral to NERS among referrers, scheme deliverers and patients. Methods Individual, semi-structured interviews were conducted with 50 stakeholders: scheme referrers (n = 9); scheme deliverers (n = 22); and referred patients (n = 19). Convenience sampling techniques were used to recruit scheme referrers and purposive sampling to recruit scheme deliverers and patients. Thematic analysis was employed. Results Analyses resulted in five key themes; referrer characteristics, geographical disparities in referral and scheme access, reinforcements for awareness of the scheme, patient characteristics and processes and context underpinning a referral. Overall there was a high concordance of views between all three stakeholder groups and barriers and facilitators were found to be entwined within and across themes. Referral barriers persisting since the earlier trial included a lack of consultation time and a lack of referral feedback. Newly identified barriers included a lack of scheme awareness and a referral system perceived to be time intensive and disjointed. Key referral facilitators included patient self-referrals, a growing scheme reputation and promotional activities of scheme deliverers. Conclusions Findings provide evidence that could inform the further development of NERS and wider exercise referral schemes to ensure the referral process is timely, efficient and equitable. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-07266-7.
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Affiliation(s)
- Kelly Morgan
- Centre for Development, Evaluation, Complexity and Implementation in Public Health Improvement (DECIPHer), School of Social Sciences, Cardiff University, 1-3 Museum Place, CF10 3BD, Cardiff, UK.
| | - Jennifer Lewis
- School of Medicine, Cardiff University, Neuadd Meirionnydd, CF14 4YS, Cardiff, UK
| | - Jemma Hawkins
- Centre for Development, Evaluation, Complexity and Implementation in Public Health Improvement (DECIPHer), School of Social Sciences, Cardiff University, 1-3 Museum Place, CF10 3BD, Cardiff, UK
| | - Graham Moore
- Centre for Development, Evaluation, Complexity and Implementation in Public Health Improvement (DECIPHer), School of Social Sciences, Cardiff University, 1-3 Museum Place, CF10 3BD, Cardiff, UK
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Robotic Roux en Y gastric bypass can be safe and cost-effective in a rural setting: clinical outcomes from a community hospital bariatric program. J Robot Surg 2021; 15:929-936. [PMID: 33507471 DOI: 10.1007/s11701-021-01193-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Accepted: 01/15/2021] [Indexed: 10/22/2022]
Abstract
Robotic Roux en Y gastric bypass (R-RYGB) is becoming more common due to the shifting trend toward robotic gastrointestinal surgery. The goal of this study is to determine if R-RYGB can be safely implemented at a robotic bariatric surgery program in a community hospital with similar results to laparoscopic RYGB (L-RYGB) in a cost-effective manner. A total of 50 R-RYGB procedures were performed with the Xi and the X da Vinci systems and compared with 50 L-RYGB cases by a single surgeon from October 2018 to January 2020 at an acute-care community hospital in a rural setting with a high-volume MBSAQIP-accredited program. A retrospective chart review was conducted with IRB approval and statistical analysis of 30-day morbidity, mortality, re-interventions, and resolution of co-morbidities, with financial analysis of cost reduction. Both groups were similar in age, gender, ASA class, co-morbidities, and body mass index (BMI). There was no mortality or anastomotic leak. The 30-day morbidity for R-RYGB was 10.0% with a re-operation rate of 4.0%. There were no conversions to open, and the mean hospital length of stay was 2.22 ± 1.19 days. There were no statistically significant differences between R-RYGB and L-RYGB with respect to any measured outcome, including intraoperative time (121.94 vs. 113.52, respectively; p = 0.1495). However, when incidences and percentages were used, R-RYGB had improved performance for most of the outcomes measuring safety. There was an average cost reduction of $816.90 per case (total saving of $40,845.00 for 50 cases) in the R-RYGB by transitioning from a hybrid approach to a totally robotic approach. R-RYGB appears to be as safe as L-RYGB and can be performed in a rural community hospital while maintaining a low complication rate, achieving a high co-morbidity resolution rate, and saving costs with a totally robotic approach.
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Badia JG, Zurro AM. [Julian Tudor Hart (1927-2018): indisputable world leader in primary care]. Aten Primaria 2019; 50:385-386. [PMID: 30056946 PMCID: PMC6837094 DOI: 10.1016/j.aprim.2018.07.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Blane DN. Medical education in (and for) areas of socio-economic deprivation in the UK. EDUCATION FOR PRIMARY CARE 2018; 29:255-258. [DOI: 10.1080/14739879.2018.1512056] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- David N. Blane
- General Practice and Primary Care, University of Glasgow, Glasgow, UK
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Bending ZJ. Reconceptualising the doctor-patient relationship: recognising the role of trust in contemporary health care. JOURNAL OF BIOETHICAL INQUIRY 2015; 12:189-202. [PMID: 25124984 DOI: 10.1007/s11673-014-9570-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/03/2013] [Accepted: 06/30/2014] [Indexed: 05/27/2023]
Abstract
The conception of the doctor-patient relationship under Australian law has followed British common law tradition whereby the relationship is founded in a contractual exchange. By contrast, this article presents a rationale and framework for an alternative model-a "Trust Model"-for implementation into law to more accurately reflect the contemporary therapeutic dynamic. The framework has four elements: (i) an assumption that professional conflicts (actual or perceived) with patient safety, motivated by financial or personal interests, should be avoided; (ii) an onus on doctors to disclose these conflicts; (iii) a proposed mechanism to contend with instances where doctors choose not to disclose; and (iv) sanctions for non-compliance with the regime.
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Affiliation(s)
- Zara J Bending
- Macquarie Law School, Macquarie University, North Ryde, 2109, Australia,
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Himmelstein DU, Ariely D, Woolhandler S. Pay-for-Performance: Toxic to Quality? Insights from Behavioral Economics. INTERNATIONAL JOURNAL OF HEALTH SERVICES 2014; 44:203-14. [DOI: 10.2190/hs.44.2.a] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Pay-for-performance programs aim to upgrade health care quality by tailoring financial incentives for desirable behaviors. While Medicare and many private insurers are charging ahead with pay-for-performance, researchers have been unable to show that it benefits patients. Findings from the new field of behavioral economics challenge the traditional economic view that monetary reward either is the only motivator or is simply additive to intrinsic motivators such as purpose or altruism. Studies have shown that monetary rewards can undermine motivation and worsen performance on cognitively complex and intrinsically rewarding work, suggesting that pay-for-performance may backfire.
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Hart JT. Health care or health trade? A historic moment of choice. INTERNATIONAL JOURNAL OF HEALTH SERVICES 2004; 34:245-54. [PMID: 15242157 DOI: 10.2190/wuav-yat6-mtqp-f1ub] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
During the 20th century, medical care evolved from a notional economy of trying to a real economy of doing. Care systems can therefore usefully be measured and evaluated as production systems. Whether they will succumb to the pattern of competitive commodity production for profit in the market, or will succeed in developing their own new gift economy for human needs, will become a dominant political and economic issue in the 21st century. Health care is now becoming industrialized in essentially the same way as textile manufacture was industrialized in the 19th century, with corresponding loss of control by skilled workers over their work processes. The outcome of the struggle between skilled handloom weavers and their industrializing employers was determined by the huge rise in productivity associated with machines. The outcome of current struggles between public service and state-subsidized corporate care for profit will be decided likewise by superior productivity. Evidence suggests that in terms of health outcome, democratized public care with a much expanded and diversified workforce could be far more productive than industrialization.
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Affiliation(s)
- Julian Tudor Hart
- Department of Primary Care, Clinical School, University of Wales Swansea, UK.
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Affiliation(s)
- Robert Moorhead
- Discipline of General Practice, University of Western Australia, 328 Stirling Hwy, Claremont 6010, Western Australia.
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Affiliation(s)
- Robert Moorhead
- Discipline of General Practice, University of Western Australia, 328 Stirling Hwy, Claremont 6010, Western Australia.
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Eisenberg L. Past, present, and future of psychiatry: personal reflections. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 1997; 42:705-13. [PMID: 9307830 DOI: 10.1177/070674379704200702] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To review the past half century of North American psychiatry from personal experience and to gauge its future prospects. METHODS An examination of the relevant literature, recollections from a long academic career, and analysis of trends. RESULTS The pendulum of psychiatric theory continues its swing from its psychological to its biological pole; current economic forces are driving it toward reductionistic biology. The very considerable gains in the psychosocial and neurobiogical knowledge base of our field will ultimately have a potent yield in patient care once the restrictive controls on its application to service provision are lifted. CONCLUSION The future of research in the sciences basic to psychiatry has never been more promising. How rapidly progress will occur will be a function of the resources society is willing to commit to mental health research. The prognosis for the translation of the new findings to clinical practice will depend on whether professionals can mobilize public support for quality care for the mentally ill.
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Affiliation(s)
- L Eisenberg
- Department of Social Medicine, Harvard Medical School, Boston, MA 02115, USA
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Affiliation(s)
- S Woolhandler
- Center for National Health Program Studies, Cambridge Hospital/Harvard Medical School, Cambridge, Mass, USA
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Affiliation(s)
- P Fugelli
- Institute for Social Medicine, University of Oslo, Norway
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Abstract
Monitoring and feedback of diagnostic errors is essential for quality diagnosis and inimical to the direction in which the United States health delivery system is heading. Tracking diagnosis evolution longitudinally can provide rich clinical insights to improve the timeliness and accuracy of diagnosis, yet we lack even primitive systems to accomplish this function. Ten examples are listed, illustrating key questions regarding misdiagnosis. A system for tracking admitting diagnosis revision is presented as a primitive diagnosis tracking prototype. An automated system is required to generalize this system to a longitudinal outpatient setting. The perils in the implementation of diagnosis tracking include the potential for fear-inducing punitive application, tampering with appropriate diagnostic strategies due to failure to distinguish common from special cause variation, and the affixing of "price tags" to diagnoses. The latter is an especially worrisome side effect of market-driven health reform, and threatens the success of the project.
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Affiliation(s)
- G D Schiff
- Department of Medicine, Cook County Hospital, Chicago IL 60612
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Woolhandler S, Himmelstein DU. Clinton's health plan: Prudential's choice. INTERNATIONAL JOURNAL OF HEALTH SERVICES 1994; 24:583-92. [PMID: 7896463 DOI: 10.2190/qgaf-7lu5-fk81-j6a8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
President Clinton has proposed a managed competition model for health care reform. This strategy would accelerate the corporatization of U.S. health care resulting in more bureaucracy, less patient choice, and a health system owned by a few insurance giants. There is no evidence that competition or other central features of Clinton's plan can lower costs or improve quality. Because cost containment is doubtful, the promised expansion of coverage is unlikely to be implemented.
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Affiliation(s)
- S Woolhandler
- Center for National Health Program Studies, The Cambridge Hospital/Harvard Medical School, MA 02139
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Affiliation(s)
- W A Silverman
- Department of Pediatrics, Columbia University, College of Physicians & Surgeons, New York, NY 10032
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Sheldon TA, Smith GD, Bevan G. Weighting in the dark: resource allocation in the new NHS. BMJ (CLINICAL RESEARCH ED.) 1993; 306:835-9. [PMID: 8357370 PMCID: PMC1677282 DOI: 10.1136/bmj.306.6881.835] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
National allocation of resources to regional health authorities and by them to districts is now determined by a weighted capitation formula. The national formula was derived from regression analysis, with hospital utilisation as an index of need for health care--a method which has fundamental limitations. This paper argues that the search for an empirically based resource allocation formula of high precision in the name of promotion of equity is largely fruitless given the impossibility of measuring the true need for, and costs of, providing health care, especially with the limited data available. The inclusion of measures of social deprivation is also poorly thought out. The availability of data from the 1991 census, which included a question regarding long-standing illness, together with the intention of the Department of Health to review the weighted capitation formula using this information may stimulate much work but little light. It is essential that the impact of resource allocation formulas is justifiable on grounds other than the composition of any particular formula.
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Affiliation(s)
- T A Sheldon
- Centre for Health Economics, University of York, Heslington
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