What's keeping us so busy in primary care? A snapshot from one practice

Disparities in the Timeliness of Addressing Patient-Initiated Telephone Calls in a Primary Care Clinic: The Impact of Quality Improvement Interventions

A timely response to patient-initiated telephone calls can affect many aspects of patient health, including quality of care and health equity. Historically, at a family medicine residency clinic, at least 1 out of 4 patient calls remained unresolved three days after the call was placed. We sought to explore whether there were differential delays in resolution of patient concerns for certain groups and how these were affected by quality improvement interventions to increase responsiveness to patient calls. A multidisciplinary team at a primary care residency clinic applied Lean education and tools to improve the timeliness of addressing telephone encounters. Telephone encounter data were obtained for one year before and nine months after the intervention. Data were stratified by race, ethnicity, preferred language, sex, online portal activation status, age category, zip code, patient risk category, and reason for call. Stratified data revealed consistently worse performance on telephone encounter closure by 72 hours for Black/African American patients compared to Hispanic and non-Hispanic White patients pre-intervention. Interventions resulted in statistically significant overall improvement, with an OR of 2.9 (95% CI: 2.62 to 3.21). Though interventions did not target a specific population, pre-intervention differences based on race and ethnicity resolved post-intervention. Telephone calls serve as an important means of patient communication with care teams. General interventions to improve the timeliness of addressing telephone encounters can lead to sustainable improvement in a primary care academic clinic and may also alleviate disparities.

Using Behavioral Economics to Reduce Low-Value Care Among Older Adults: A Cluster Randomized Clinical Trial

Importance

Use of low-value care is common among older adults. It is unclear how to best engage clinicians and older patients to decrease use of low-value services.

Objective

To test whether the Committing to Choose Wisely behavioral economic intervention could engage primary care clinicians and older patients to reduce low-value care.

Design, Setting, and Participants

Stepped-wedge cluster randomized clinical trial conducted at 8 primary care clinics of an academic health system and a private group practice between December 12, 2017, and September 4, 2019. Participants were primary care clinicians and older adult patients who had diabetes, insomnia, or anxiety or were eligible for prostate cancer screening. Data analysis was performed from October 2019 to November 2023.

Intervention

Clinicians were invited to commit in writing to Choosing Wisely recommendations for older patients to avoid use of hypoglycemic medications to achieve tight glycemic control, sedative-hypnotic medications for insomnia or anxiety, and prostate-specific antigen tests to screen for prostate cancer. Committed clinicians had their photographs displayed on clinic posters and received weekly emails with alternatives to these low-value services. Educational handouts were mailed to applicable patients before scheduled visits and available at the point of care.

Main Outcomes and Measures

Patient-months with a low-value service across conditions (primary outcome) and separately for each condition (secondary outcomes). For patients with diabetes, or insomnia or anxiety, secondary outcomes were patient-months in which targeted medications were decreased or stopped (ie, deintensified).

Results

The study included 81 primary care clinicians and 8030 older adult patients (mean [SD] age, 75.1 [7.2] years; 4076 men [50.8%] and 3954 women [49.2%]). Across conditions, a low-value service was used in 7627 of the 37 116 control patient-months (20.5%) and 7416 of the 46 381 intervention patient-months (16.0%) (adjusted odds ratio, 0.79; 95% CI, 0.65-0.97). For each individual condition, there were no significant differences between the control and intervention periods in the odds of patient-months with a low-value service. The intervention increased the odds of deintensification of hypoglycemic medications for diabetes (adjusted odds ratio, 1.85; 95% CI, 1.06-3.24) but not sedative-hypnotic medications for insomnia or anxiety.

Conclusions and Relevance

In this stepped-wedge cluster randomized clinical trial, the Committing to Choose Wisely behavioral economic intervention reduced low-value care across 3 common clinical situations and increased deintensification of hypoglycemic medications for diabetes. Use of scalable interventions that nudge patients and clinicians to achieve greater value while preserving autonomy in decision-making should be explored more broadly.

Trial Registration

ClinicalTrials.gov Identifier: NCT03411525.

Characterizing the Patterns of Electronic Health Record-Integrated Secure Messaging Use: Cross-Sectional Study

BACKGROUND

Communication among health care professionals is essential for the delivery of safe clinical care. Secure messaging has rapidly emerged as a new mode of asynchronous communication. Despite its popularity, relatively little is known about how secure messaging is used and how such use contributes to communication burden.

OBJECTIVE

This study aims to characterize the use of an electronic health record-integrated secure messaging platform across 14 hospitals and 263 outpatient clinics within a large health care system.

METHODS

We collected metadata on the use of the Epic Systems Secure Chat platform for 6 months (July 2022 to January 2023). Information was retrieved on message volume, response times, message characteristics, messages sent and received by users, user roles, and work settings (inpatient vs outpatient).

RESULTS

A total of 32,881 users sent 9,639,149 messages during the study. Median daily message volume was 53,951 during the first 2 weeks of the study and 69,526 during the last 2 weeks, resulting in an overall increase of 29% (P=.03). Nurses were the most frequent users of secure messaging (3,884,270/9,639,149, 40% messages), followed by physicians (2,387,634/9,639,149, 25% messages), and medical assistants (1,135,577/9,639,149, 12% messages). Daily message frequency varied across users; inpatient advanced practice providers and social workers interacted with the highest number of messages per day (median 19). Conversations were predominantly between 2 users (1,258,036/1,547,879, 81% conversations), with a median of 2 conversational turns and a median response time of 2.4 minutes. The largest proportion of inpatient messages was from nurses to physicians (972,243/4,749,186, 20% messages) and physicians to nurses (606,576/4,749,186, 13% messages), while the largest proportion of outpatient messages was from physicians to nurses (344,048/2,192,488, 16% messages) and medical assistants to other medical assistants (236,694/2,192,488, 11% messages).

CONCLUSIONS

Secure messaging was widely used by a diverse range of health care professionals, with ongoing growth throughout the study and many users interacting with more than 20 messages per day. The short message response times and high messaging volume observed highlight the interruptive nature of secure messaging, raising questions about its potentially harmful effects on clinician workflow, cognition, and errors.

Pragmatic Clinical Trial of Population Health, Portal-Based Depression Screening: the PORTAL-Depression Study

BACKGROUND

A population health approach to depression screening using patient portals may be a promising strategy to proactively engage and identify patients with depression.

OBJECTIVE

To determine whether a population health approach to depression screening is more effective than screening during clinic appointments alone for identifying patients with depression.

DESIGN

A pragmatic clinical trial at an adult outpatient internal medicine clinic at an urban, academic, tertiary care center.

PATIENTS

Eligible patients (n = 2713) were adults due for depression screening with active portal accounts. Patients with documented depression or bipolar disorder and those who had been screened in the year prior to the study were excluded.

INTERVENTION

Patients were randomly assigned to usual (n = 1372) or population healthcare (n = 1341). For usual care, patients were screened by medical assistants during clinic appointments. Population healthcare patients were sent letters through the portal inviting them to fill out an online screener regardless of whether they had a scheduled appointment. The same screening tool, the Computerized Adaptive Test for Mental Health (CAT-MH™), was used for clinic- and portal-based screening.

MAIN MEASURES

The primary outcome was the depression screening rate.

KEY RESULTS

The depression screening rate in the population healthcare arm was higher than that in the usual care arm (43% (n = 578) vs. 33% (n = 459), p < 0.0001). The rate of positive screens was also higher in the population healthcare arm compared to that in the usual care (10% (n = 58) vs. 4% (n = 17), p < 0.001).

CONCLUSION

Findings suggest depression screening via a portal as part of a population health approach can increase screening and case identification, compared to usual care.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03832283.

Influence of data disclosures on physician decisions about off-label uses: findings from a qualitative study

Background

Prescribing approved products for unapproved uses (off-label use) is not uncommon among physicians in certain medical specialties. Available evidence about an off-label use – both supportive and unsupportive – can influence prescribers’ decisions about a drug’s appropriateness for a particular case. The objectives of this study were: (1) to examine physician perceptions about off-label uses generally, including their awareness of unsupportive data; and (2) to explore the influence of disclosure information about unsupportive data on off-label prescribing decisions.

Methods

Semi-structured interviews were conducted between December 2019 and January 2020 with oncologists (n = 35) and primary care physicians (n = 35). Interviews explored general prescribing practices, understanding of and information sources for learning about off-label use of prescription drugs, awareness of unsupportive data related to off-label uses, and preferences and reactions to disclosure statements about the existence of unsupportive data related to an off-label use.

Results

Most participants reported prescribing drugs for off-label uses (with half reporting regular off-label prescribing). However, among those who prescribe off-label, approximately two-thirds had never seen unsupportive data about off-label uses. Physicians preferred a disclosure statement that provided a summary of the unsupportive data about the off-label use; this statement also led most physicians to say they were unlikely or less likely to prescribe the drug for that use.

Conclusions

This study suggests that physicians’ decision-making about prescribing for off-label uses of approved drugs may be influenced by awareness of unsupportive data. Our interviews also suggest that providing more information about unsupportive study findings may result in a reduction in reported prescribing likelihood.

The Underuse of Medicare's Prevention and Coordination Codes in Primary Care : A Cross-Sectional and Modeling Study

BACKGROUND

Efforts to better support primary care include the addition of primary care-focused billing codes to the Medicare Physician Fee Schedule (MPFS).

OBJECTIVE

To examine potential and actual use by primary care physicians (PCPs) of the prevention and coordination codes that have been added to the MPFS.

DESIGN

Cross-sectional and modeling study.

SETTING

Nationally representative claims and survey data.

PARTICIPANTS

Medicare patients.

MEASUREMENTS

Frequency of use and estimated Medicare revenue involving 34 billing codes representing prevention and coordination services for which PCPs could but do not necessarily bill.

RESULTS

Eligibility among Medicare patients for each service ranged from 8.8% to 100%. Among eligible patients, the median use of billing codes was 2.3%, even though PCPs provided code-appropriate services to more patients, for example, to 5.0% to 60.6% of patients eligible for prevention services. If a PCP provided and billed all prevention and coordination services to half of all eligible patients, the PCP could add to the practice's annual revenue $124 435 (interquartile range [IQR], $30 654 to $226 813) for prevention services and $86 082 (IQR, $18 011 to $154 152) for coordination services.

LIMITATION

Service provision based on survey questions may not reflect all billing requirements; revenues do not incorporate the compliance, billing, and opportunity costs that may be incurred when using these codes.

CONCLUSION

Primary care physicians forego considerable amounts of revenue because they infrequently use billing codes for prevention and coordination services despite having eligible patients and providing code-appropriate services to some of those patients. Therefore, creating additional billing codes for distinct activities in the MPFS may not be an effective strategy for supporting primary care.

PRIMARY FUNDING SOURCE

National Institute on Aging.

Toward Pre-Diagnostic Detection of Dementia in Primary Care

Background: Preventing dementia warrants the pragmatic engagement of primary care. Objective: This study predicted conversion to dementia 12 months before diagnosis with indicators that primary care can utilize within the practical constraints of routine practice. Methods: The study analyzed data from the Alzheimer’s Disease Neuroimaging Initiative (Total sample = 645, converting participants = 54). It predicted the conversion from biological (plasma neurofilament light chain), cognitive (Trails Making Test– B), and functional (Functional Activities Questionnaire) measures, in addition to demographic variables (age and education). Results: A Gradient Booster Trees classifier effectively predicted the conversion, based on a Synthetic Minority Oversampling Technique (n = 1,290, F1 Score = 92, AUC = 94, Recall = 87, Precision = 97, Accuracy = 92). Subsequent analysis indicated that the MCI False Positive group (i.e., non-converting participants with cognitive impairment flagged by the model for prospective conversion) scored significantly lower on multiple cognitive tests (Montreal Cognitive Assessment, p < 0.002; ADAS-13, p < 0.0004; Rey Auditory Verbal Learning Test, p < 0.002/0.003) than the MCI True Negative group (i.e., correctly classified non-converting participants with cognitive impairment). These groups also differed in CSF tau levels (p < 0.04), while consistent effect size differences emerged in the all-pairwise comparisons of hippocampal volume and CSF Aβ1 - 42. Conclusion: The model effectively predicted 12-month conversion to dementia and further identified non-converting participants with MCI, in the False Positive group, at relatively higher neurocognitive risk. Future studies may seek to extend these results to earlier prodromal phases. Detection of dementia before diagnosis may be feasible and practical in primary care settings, pending replication of these findings in diverse clinical samples.

The Distressed State of Primary Care in Virginia Pre-Medicaid Expansion and Pre-Pandemic

BACKGROUND

Primary care is crucial to the health of individuals and communities, but it faces numerous structural and systemic challenges. Our study assessed the state of primary care in Virginia to prepare for Medicaid expansion. It also provides insight into the frontline of health care prior to an unprecedented global COVID-19 pandemic.

METHODS

We surveyed 1622 primary care practices to understand organizational characteristics, scope of care, capacity, and organizational stress.

RESULTS

Practices (484) varied in type, ownership, location, and care for medically underserved and diverse patient populations. Most practices accepted uninsured and Medicaid patients. Practices reported a broad scope of care, including offering behavioral health and medication-assisted therapy for opioid addiction. Over half addressed social needs like transportation and unstable housing. One in three practices experienced a significant stress in 2019, prepandemic, and only 18.8% of practices anticipated a stress in 2020.

CONCLUSIONS

Primary care serves as the foundation of our health care system and is an essential service, but it is severely stressed, under-resourced, and overburdened in the best of times. Primary care needs strategic workforce planning, adequate access to resources, and financial investment to sustain its value and innovation.

How Physicians Spend Their Work Time: an Ecological Momentary Assessment

BACKGROUND

Little is known about how physicians spend their work time.

OBJECTIVE

To determine how physicians in outpatient care spend their time at work, using an innovative method: ecological momentary assessment (EMA).

DESIGN

Physician activity was measured via EMA, using a smartphone app.

PARTICIPANTS

Twenty-eight practices across 16 US states. Sixty-one physicians: general internal medicine, family medicine, non-interventional cardiology, orthopedics.

MAIN MEASURES

Proportions of time spent on 14 activities within 6 broad categories of work: direct patient care (including both face-to-face care and other patient care-related activities), electronic health record (EHR) input, administration, teaching/supervising, personal time, and other.

KEY RESULTS

After excluding personal time, physicians spent 66.5% of their time on direct patient care (23.6% multitasking with use of the EHR and 42.9% without the EHR), 20.7% on EHR input alone, 7.7% on administrative activities, and 5.0% on other activities (0.6% using the EHR). In total, physicians spent 44.9% of their time on the EHR.

LIMITATIONS

Unable to measure time spent at home on the EHR or other work tasks; participating physicians were not a random sample of US physicians.

CONCLUSIONS

The efficiency of highly trained professionals spending only two-thirds of their time on direct patient care may be questioned. EHR use continues to account for a large proportion of physician time. Further attempts should be made to redesign both EHRs and physician work processes.

Care Management and Care Coordination Within a Patient-Centered Medical Home

OBJECTIVE

The aim of this study was to analyze perceptions and experiences of clinicians implementing the patient-centered medical home (PCMH).

BACKGROUND

The PCMH model focuses on several important concepts, including team-based care management as well as care coordination and continuity among providers and across settings of care.

METHODS

A qualitative analysis of data collected in 2016 from primary care personnel through a national survey was conducted.

RESULTS

Four themes were found consistent with care management and care coordination: the importance of teamwork and optimized team member roles, need for adequate prioritization of care management and care coordination, need to refine tools and resources supporting care management and care coordination, and challenges with managing and coordinating care with and across complex systems.

CONCLUSIONS

Successful implementation requires adequate support for teamwork and ensuring team members can work according to their clinical competency. Nurses practicing in expanded roles need clear role guidelines and adequate time to function in these roles.

Educating military primary health-care providers in genomic medicine: lessons learned from the MilSeq Project

PURPOSE

With few trained genetics professionals, the Military Health System is ill-equipped to manage the rapid expansion of genomic medicine. The MilSeq Project introduces an alternative service delivery model (ASDM) in which primary health-care providers (HCPs) provide post-test counseling (PTC) to healthy Airmen who have undergone exome sequencing. We describe HCP performance after a prerequisite educational intervention (EI).

METHODS

After a brief EI and pre-/posteducation surveys, HCPs were eligible to provide PTC with a genetic counselor available for consult. PTC was recorded, transcribed, and reviewed. Opportunities for improvement were organized into four error adjustment categories: (1) knowledge limitation, (2) minor, (3) moderate, and (4) critical. Thematic analysis was also performed.

RESULTS

Pre-/posteducation survey responses revealed statistically significant improvements in all domains. Minor error adjustments were most represented (n = 93), followed by knowledge limitation (n = 39) and moderate (n = 19). No critical errors were identified, and 17 transcripts required no adjustment. Thematic analysis revealed four themes that would benefit from more focused education: (1) family-centered care, (2) conveying risk, (3) disease knowledge, and (4) assay knowledge.

CONCLUSION

HCPs demonstrated competence in basic PTC after a brief EI. This ASDM may be a viable interim response to the shortage of genetics professionals in some systems.

Person-centred and efficient care delivery for high-need, high-cost patients: primary care professionals' experiences

Background

High-need, high-cost (HNHC) patients, who typically have complex and long-term care demands, contribute considerably to the high work pressure of primary care professionals (PCPs). To improve patient as well as provider experiences, it is crucial to take into account the PCPs’ perspective in designing health care strategies for HNHC patients. Therefore, this study aimed to create insight into PCPs’ experienced barriers and possible solutions with regards to person-centred, efficient care delivery to HNHC patients.

Methods

We conducted a qualitative study using focus group interviews with PCPs at a Dutch primary care group. A semi-structured interview guide was developed for the interviews. Qualitative content analysis was employed deductively by means of a categorisation matrix. The matrix was based on the components retrieved from the SELFIE framework for integrated care for multi-morbidity.

Results

Forty-two PCPs participated in five focus group interviews. Discussed barriers and solutions were related to the core of the SELFIE framework (i.e. the individual and environment), and particularly four of the six health system components in the framework: service delivery, leadership & governance, workforce, and technologies & medical products. Many discussed barriers revolved around the complex biopsychosocial needs of HNHC patients: PCPs reported a lack of time (service delivery), insufficiently skilled PCPs (workforce), and inefficient patient information retrieval and sharing (technologies & medical products) as barriers to adequately meet the biopsychosocial needs of HNHC patients.

Conclusions

This qualitative study suggests that primary care is currently insufficiently equipped to accommodate the complex biopsychosocial needs of HNHC patients. Therefore, it is firstly important to strengthen primary care internally, taking into account the experienced lack of time, the insufficient number of equipped PCPs and lack of inter-professional information retrieval and sharing. Secondly, PCPs should be supported in cooperating and communicating more efficiently with health services outside primary care to adequately deliver person-centred, efficient care. As a prerequisite, it is crucial to direct policy efforts at the design of a strong system of social and community services. In terms of future research, it is important to assess the feasibility and effects of re-designing primary care based on the provided recommendations.

Relationship between number of health problems addressed during a primary care patient visit and clinician workload

INTRODUCTION

Primary care is complex due to multiple health problems being addressed in each patient visit. Little is known about the effect of the number of problems per encounter (NPPE) on the resulting clinician workload (CWL), as measured using the National Aeronautics and Space Administration Task Load Index (NASA-TLX).

METHODS

We evaluated the relationship between NPPE and CWL across 608 adult patient visits, conducted by 31 clinicians, using hierarchical linear regression. Clinicians were interviewed about outlier visits to identify reasons for higher or lower than expected CWL.

RESULTS

Mean NPPE was 3.30 ± 2.0 (sd) and CWL was 47.6 ± 18.4 from a maximum of 100. Mental demand, time demand and effort accounted for 71.5% of CWL. After adjustment for confounders, each additional problem increased CWL by 3.9 points (P < 0.001). Patient, problem, environmental and patient-physician relationship factors were qualitatively identified from interviews as moderators of this effect.

CONCLUSION

CWL is positively related to NPPE. Several modifiable factors may enhance or mitigate this effect. Our findings have implications for using a Human Factors (HF) approach to managing CWL.

Impacts of Operational Failures on Primary Care Physicians' Work: A Critical Interpretive Synthesis of the Literature

PURPOSE

Operational failures are system-level errors in the supply of information, equipment, and materials to health care personnel. We aimed to review and synthesize the research literature to determine how operational failures in primary care affect the work of primary care physicians.

METHODS

We conducted a critical interpretive synthesis. We searched 7 databases for papers published in English from database inception until October 2017 for primary research of any design that addressed problems interfering with primary care physicians' work. All potentially eligible titles/abstracts were screened by 1 reviewer; 30% were subject to second screening. We conducted an iterative critique, analysis, and synthesis of included studies.

RESULTS

Our search retrieved 8,544 unique citations. Though no paper explicitly referred to "operational failures," we identified 95 papers that conformed to our general definition. The included studies show a gap between what physicians perceived they should be doing and what they were doing, which was strongly linked to operational failures-including those relating to technology, information, and coordination-over which physicians often had limited control. Operational failures actively configured physicians' work by requiring significant compensatory labor to deliver the goals of care. This labor was typically unaccounted for in scheduling or reward systems and had adverse consequences for physician and patient experience.

CONCLUSIONS

Primary care physicians' efforts to compensate for suboptimal work systems are often concealed, risking an incomplete picture of the work they do and problems they routinely face. Future research must identify which operational failures are highest impact and tractable to improvement.

What Is the Optimal Primary Care Panel Size?: A Systematic Review

BACKGROUND

Primary care for a panel of patients is a central component of population health, but the optimal panel size is unclear.

PURPOSE

To review evidence about the association of primary care panel size with health care outcomes and provider burnout.

DATA SOURCES

English-language searches of multiple databases from inception to October 2019 and Google searches performed in September 2019.

STUDY SELECTION

English-language studies of any design, including simulation models, that assessed the association between primary care panel size and safety, efficacy, patient-centeredness, timeliness, efficiency, equity, or provider burnout.

DATA EXTRACTION

Independent, dual-reviewer extraction; group consensus rating of certainty of evidence.

DATA SYNTHESIS

Sixteen hypothesis-testing studies and 12 simulation modeling studies met inclusion criteria. All but 1 hypothesis-testing study were cross-sectional assessments of association. Three studies each provided low-certainty evidence that increasing panel size was associated with no or modestly adverse effects on patient-centered and effective care. Eight studies provided low-certainty evidence that increasing panel size was associated with variable effects on timely care. No studies assessed the effect of panel size on safety, efficiency, or equity. One study provided very-low-certainty evidence of an association between increased panel size and provider burnout. The 12 simulation studies evaluated 5 models; all used access as the only outcome of care. Five and 2 studies, respectively, provided moderate-certainty evidence that adjusting panel size for case mix and adding clinical conditions to the case mix resulted in better access.

LIMITATION

No studies had concurrent comparison groups, and published and unpublished studies may have been missed.

CONCLUSION

Evidence is insufficient to make evidence-based recommendations about the optimal primary care panel size for achieving beneficial health outcomes.

PRIMARY FUNDING SOURCE

Veterans Affairs Quality Enhancement Research Initiative.

Organizational strategies to reduce physician burnout and improve professional fulfillment

Burnout is highly prevalent among physicians and has been associated with negative outcomes for physicians, patients, staff, and health-care organizations. Reducing physician burnout and increasing physician well-being is a priority. Systematic reviews suggest that organization-based interventions are more effective in reducing physician burnout than interventions targeted at individual physicians. This consensus review by leaders in the field across multiple institutions presents emerging trends and exemplary evidence-based strategies to improve professional fulfillment and reduce physician burnout using Stanford's tripartite model of physician professional fulfillment as an organizing framework: practice efficiency, culture, and personal resilience to support physician well-being. These strategies include leadership traits, latitude of control and autonomy, collegiality, diversity, teamwork, top-of-license workflows, electronic health record (EHR) usability, peer support, confidential mental health services, work-life integration and reducing barriers to practicing a healthy lifestyle. The review concludes with evidence-based recommendations on establishing an effective physician wellness program.

An observational study of a clinical guideline implementation project in primary care

Explorations of workflow development within primary care allow us to understand initial steps in the pace of knowledge and practice acclimatization within clinics. This study describes use of practice facilitation as an implementation strategy to communicate shared project goals and monitor and support refinement of practice behavior. This study engaged eight health care organizations, including 55 primary care practices, ≈380 clinicians, and ≈620 nursing and support staff in a guideline implementation project regarding United States Preventive Services Task Force use of aspirin recommendations for primary prevention of cardiovascular events.

Health Care Value: Relationships Between Population Health, Patient Experience, and Costs of Care

Health care delivery in the United States has become complex and inefficient. With national health care gross domestic product and out-of-pocket expenses increasing, the nation has not yet improved the quality of health care compared with similar nations. As a result, the public asks for greater population health, improved patient experience, and reduced expenses. In this article, the author discuss how key stakeholders, including policy makers, health systems, patients, and employers, understand how these components of health care value are defined, interlink, and provide opportunities for improvement. The author also outlines concrete improvement opportunities from across the country.

The Primary Care Behavioral Health (PCBH) Model: An Overview and Operational Definition

The Primary Care Behavioral Health (PCBH) model is a prominent approach to the integration of behavioral health services into primary care settings. Implementation of the PCBH model has grown over the past two decades, yet research and training efforts have been slowed by inconsistent terminology and lack of a concise, operationalized definition of the model and its key components. This article provides the first concise operationalized definition of the PCBH model, developed from examination of multiple published resources and consultation with nationally recognized PCBH model experts. The definition frames the model as a team-based approach to managing biopsychosocial issues that present in primary care, with the over-arching goal of improving primary care in general. The article provides a description of the key components and strategies used in the model, the rationale for those strategies, a brief comparison of this model to other integration approaches, a focused summary of PCBH model outcomes, and an overview of common challenges to implementing the model.

Rebuilding the Standing Prescription Renewal Orders

BACKGROUND

Managing prescription renewal requests is a labor-intensive challenge in ambulatory care. In 2009, Vanderbilt University Medical Center developed clinic-specific standing prescription renewal orders that allowed nurses, under specific conditions, to authorize renewal requests. Formulary and authorization changes made maintaining these documents very challenging.

OBJECTIVE

This article aims to review, standardize, and restructure legacy standing prescription renewal orders into a modular, scalable, and easier to manage format for conversion and use in a new electronic health record (EHR).

METHODS

We created an enterprise-wide renewal domain model using modular subgroups within the main institutional standing renewal order policy by extracting metadata, medication group names, medication ingredient names, and renewal criteria from approved legacy standing renewal orders. Instance-based matching compared medication groups in a pairwise manner to calculate a similarity score between medication groups. We grouped and standardized medication groups with high similarity by mapping them to medication classes from a medication terminology vendor and filtering them by intended route (e.g., oral, subcutaneous, inhalation). After standardizing the renewal criteria to a short list of reusable criteria, the Pharmacy and Therapeutics (P&T) committee reviewed and approved candidate medication groups and corresponding renewal criteria.

RESULTS

Seventy-eight legacy standing prescription renewal orders covered 135 clinics (some applied to multiple clinics). Several standing orders were perfectly congruent, listing identical medications for renewal. We consolidated 870 distinct medication classes to 164 subgroups and assigned renewal criteria. We consolidated 379 distinct legacy renewal criteria to 21 criteria. After approval by the P&T committee, we built subgroups in a structured and consistent format in the new EHR, where they facilitated chart review and standing order adherence by nurses. Additionally, clinicians could search an autogenerated document of the standing order content from the EHR data warehouse.

CONCLUSION

We describe a methodology for standardizing and scaling standing prescription renewal orders at an enterprise level while transitioning to a new EHR.

Effects of mindfulness training on perceived stress, self-compassion, and self-reflection of primary care physicians: a mixed-methods study

BACKGROUND

Primary care physicians are subjected to a high workload, which can lead to stress and a high incidence of burnout. A mindfulness training course was developed and implemented for primary care physicians to better cope with stress and improve job functioning.

AIM

To gain insight into the effects of the mindfulness training on perceived stress, self-compassion, and self-reflection of primary care physicians.

DESIGN & SETTING

A pragmatic mixed-methods pre-post design in which physicians received 8 weeks of mindfulness training.

METHOD

Participants completed validated questionnaires on perceived stress (Perceived Stress Scale [PSS]), self-compassion (Self-Compassion Scale [SCS]), and self-reflection (Groningen Reflection Ability Scale [GRAS]) before the training, directly after, and 6 months later. Semi-structured interviews were conducted with six participants after the training and a content analysis was performed to gain in depth understanding of experiences.

RESULTS

A total of 54 physicians participated in the study. PSS was reduced (mean difference [MD] -4.5, P<0.001), SCS improved (MD = 0.5, P<0.001), and GRAS improved (MD = 3.3, P<0.001), directly after the 8-week training compared with before training. Six months later, PSS was still reduced (MD = -2.9, P = 0.025) and SCS improved (MD = 0.7, P<0.001). GRAS did not remain significant (MD = 2.5, P = 0.120). Qualitative analysis revealed four themes: being more aware of their own feelings and thoughts; being better able to accept situations; experiencing more peacefulness; and having more openness to the self and others.

CONCLUSION

Mindfulness training might be an effective approach for improving stress resilience, self-compassion, and self-reflection in primary care physicians.

Understanding Primary Care Provider Attitudes and Behaviors Regarding Cardiovascular Disease Risk and Diabetes Prevention in the Northern Midwest

IN BRIEF We sought to fill critical gaps in understanding primary care providers' (PCPs') beliefs regarding diabetes prevention and cardiovascular disease risk in the prediabetes population, including through comparison of attitudes between rural and non-rural PCPs. We used data from a 2016 cross-sectional survey sent to 299 PCPs practicing in 36 primary clinics that are part of a randomized control trial in a predominately rural northern Midwestern integrated health care system. Results showed a few significant, but clinically marginal, differences between rural and non-rural PCPs. Generally, PCPs agreed with the importance of screening for prediabetes and thoroughly and clearly discussing CV risk with high-risk patients.

Preventive visit among older adults with Medicare's introduction of Annual Wellness Visit: Closing gaps in underutilization

Preventive visit rates are low among older adults in the United States. We evaluated changes in preventive visit utilization with Medicare's introduction of Annual Wellness Visits (AWVs) in 2011. We further assessed how coverage expansion differentially affected older adults who were previously underutilizing the service. The study included Medicare beneficiaries aged 65 to 85 from a mixed-payer multispecialty outpatient healthcare organization in northern California between 2007 and 2016. Data from the electronic health records were used, and the unit of analysis was patient-year (N = 456,281). Multivariable logistic regression models were used to assess determinants of "any preventive visit" use. Prior to the AWV coverage (2007-2010), Medicare beneficiaries who were older, with serious chronic conditions, and with a fee-for-services (FFS) plan underutilized preventive visits such that odds ratio (OR) for age groups (vs. age 65-69) ranges from 0.826 (age 70-74) to 0.522 (age 80-85); for Charlson comorbidity index (CCI) (vs. 0 CCI) ranges from 0.77 (1 CCI) to 0.65 (≥2 CCI); and for FFS (vs. HMO) is 0.236. With the Medicare coverage (2011-2016), the age-based gap reduced substantially, but the difference persisted, e.g., OR for age 80-85 (vs. 65-69) is 0.628, and FFS (vs. HMO) beneficiaries still have far lower odds of using a preventive visit (OR = 0.278). The gap based on comorbidity was not reduced. Medicare's coverage expansion facilitated the use of preventive visit particularly for older adults with more advanced age or with FFS, thereby reducing disparities in preventive visit use.

Effectiveness of traditional lectures and case methods in Swedish general practitioners' continuing medical education about COPD: a cluster randomised controlled trial

OBJECTIVES

To study the effects of continuing medical education (CME) about chronic obstructive pulmonary disease (COPD) for general practitioners (GPs) by comparing two commonly used CME methods with each other and no CME (reference group).

DESIGN

A pragmatic cluster randomised controlled trial with primary healthcare centres (PHCCs) as units of randomisation.

SETTING, PARTICIPANTS AND INTERVENTIONS

24 PHCCs in Stockholm County, Sweden, were randomised into two CME intervention arms: case method learning (CM) (n=12) and traditional lectures (TL) (n=12). A reference group without CME (n=11) was recruited separately. GPs (n=255) participated in the study arm to which their PHCC was allocated: CM, n=87; TL, n=93; and reference, n=75. Two 2-hour CME seminars were given in a period of 3 months.

PRIMARY OUTCOME MEASURES

Changes in scores between baseline and 12 months on a 13-item questionnaire about evidence-based COPD management (0-2 points/question, maximum total score 26 points).

RESULTS

133 (52%) GPs completed the questionnaire both at baseline and 12 months. Both CM and TL resulted in small yet significantly higher total scores at 12 months than at baseline (CM, 10.34 vs 11.44; TL, 10.21 vs 10.91; p<0.05); there were few significant differences between these CME methods. At both baseline and 12 months, all three groups' scores were generally high on questions about smoking cessation support and low on those that measured spirometry interpretation skills, interprofessional care and management of multimorbidity.

CONCLUSIONS

Neither short CM nor short TL CME sessions substantially improve GPs' skills in managing COPD. It is justified to challenge the use of these common CME methods as a strategy for improving GPs' level of knowledge about management of COPD and other complex chronic diseases characterised by multimorbidity.

TRIAL REGISTRATION NUMBER

NCT02213809; Results.

Meaningful use's benefits and burdens for US family physicians

Objective

The federal meaningful use (MU) program was aimed at improving adoption and use of electronic health records, but practicing physicians have criticized it. This study was aimed at quantifying the benefits (ie, usefulness) and burdens (ie, workload) of the MU program for practicing family physicians.

Materials and Methods

An interdisciplinary national panel of experts (physicians and engineers) identified the work associated with MU criteria during patient encounters. They conducted a national survey to assess each criterion's level of patient benefit and compliance burden.

Results

In 2015, 480 US family physicians responded to the survey. Their demographics were comparable to US norms. Eighteen of 31 MU criteria were perceived as useful for more than half of patient encounters, with 13 of those being useful for more than two-thirds. Thirteen criteria were useful for less than half of patient encounters. Four useful criteria were reported as having a high compliance burden.

Discussion

There was high variability in physicians' perceived benefits and burdens of MU criteria. MU Stage 1 criteria, which are more related to basic/routine care, were perceived as beneficial by most physicians. Stage 2 criteria, which are more related to complex and population care, were perceived as less beneficial and more burdensome to comply with.

Conclusion

MU was discontinued, but the merit-based incentive payment system within the Medicare Access and CHIP Reauthorization Act of 2015 adopted its criteria. For many physicians, MU created a significant practice burden without clear benefits to patient care. This study suggests that policymakers should not assess MU in aggregate, but as individual criteria for open discussion.

Delivery of Standardized Patient Instructions in the After-Visit Summary Reduces Telephone Calls Between Clinic Visits

Telephone calls from patients can be a large source of between-visit work in outpatient clinics. A baseline audit at the study clinic identified medication refills and test results as the most common preventable calls. The authors created a dot phrase with standardized text detailing methods for refilling medications and reviewing test results and instructed providers to use it in the after-visit summary (AVS). After implementation of the AVS dot phrase, telephone calls for medications and results had an adjusted absolute decrease of 23.9 (95% CI = 15.4-32.4) calls per day to 16.2 (SD 7.7) calls per day, a relative reduction of 61%. Providers reported significantly fewer inbox requests for both refills ( P = .04) and test results ( P = .01). Using a standardized AVS dot phrase to inform patients on how to navigate care needs can significantly reduce between-visit workload for clinic staff and providers.

Electronic Health Record Logs Indicate That Physicians Split Time Evenly Between Seeing Patients And Desktop Medicine

Time spent by physicians is a key resource in health care delivery. This study used data captured by the access time stamp functionality of an electronic health record (EHR) to examine physician work effort. This is a potentially powerful, yet unobtrusive, way to study physicians' use of time. We used data on physicians' time allocation patterns captured by over thirty-one million EHR transactions in the period 2011-14 recorded by 471 primary care physicians, who collectively worked on 765,129 patients' EHRs. Our results suggest that the physicians logged an average of 3.08 hours on office visits and 3.17 hours on desktop medicine each day. Desktop medicine consists of activities such as communicating with patients through a secure patient portal, responding to patients' online requests for prescription refills or medical advice, ordering tests, sending staff messages, and reviewing test results. Over time, log records from physicians showed a decline in the time allocated to face-to-face visits, accompanied by an increase in time allocated to desktop medicine. Staffing and scheduling in the physician's office, as well as provider payment models for primary care practice, should account for these desktop medicine efforts.

Use of Welcome to Medicare Visits Among Older Adults Following the Affordable Care Act

INTRODUCTION

To encourage greater utilization of preventive services among Medicare beneficiaries, the 2010 Affordable Care Act waived coinsurance for the Welcome to Medicare visit, making this benefit free starting in 2011. The objective of this study was to determine the impact of the Affordable Care Act on Welcome to Medicare visit utilization.

METHODS

A 5% sample of newly enrolled fee-for-service Medicare beneficiaries for 2005-2016 was used to estimate changes in Welcome to Medicare visit use over time. An interrupted time series model examined whether Welcome to Medicare visits increased significantly after 2011, controlling for pre-intervention trends and other autocorrelation.

RESULTS

Annual Welcome to Medicare visit rates began at 1.4% in 2005 and increased to 12.3% by 2016. The quarterly Welcome to Medicare visit rate, which was almost 1% at baseline, was increasing by 0.06% before the 2011 Affordable Care Act provision (p<0.001). Immediately following the 2011 Affordable Care Act provision, the rate increased by about 1% in the first quarter of 2011 (intercept, p<0.001), followed by an increase of 0.13% every subsequent quarter (slope, p<0.001). This general trend was observed in subgroup analyses, although this trend varied by subgroups where the pre-Affordable Care Act trends of lower utilization persisted over time for non-whites and improved less quickly for men, regions other than Northeast, and beneficiaries without any supplemental insurance.

CONCLUSIONS

The Affordable Care Act, and perhaps the removal of cost sharing, was associated with increased use of the Welcome to Medicare visit; however, even with the increased use, there is room for improvement.

Evaluation of a Clinical Pharmacist-Led Multidisciplinary Antidepressant Telemonitoring Service in the Primary Care Setting

Guidelines recommend patient follow-up within 2 weeks of antidepressant initiation or uptitration to minimize treatment discontinuation and suicidal ideation risks; however, time constraints and lack of systematic processes remain barriers in primary care. A pharmacist-led multidisciplinary telemonitoring service aimed to address these barriers. This was a retrospective, observational study of adults with depression initiated or uptitrated on an antidepressant between May and October 2016. Outcomes included the proportion of eligible patients successfully contacted, adherence, adverse effects, suicidal ideations, and pharmacist interventions. Clinical pharmacists successfully reached 258 of 380 (68%) patients and provided follow-up in 298 calls. Patients endorsed antidepressant nonadherence during 56 (19%) calls, adverse effects in 81 (27%) calls, and suicidal ideations in 13 (4%) calls. Pharmacists provided 109 total interventions for 102 patients. The clinical pharmacist-led multidisciplinary antidepressant telemonitoring service is an alternative resource to monitor patients after antidepressant initiation or titration in primary care settings.

Precommitting to choose wisely about low-value services: a stepped wedge cluster randomised trial

Background

Little is known about how to discourage clinicians from ordering low-value services. Our objective was to test whether clinicians committing their future selves (ie, precommitting) to follow Choosing Wisely recommendations with decision supports could decrease potentially low-value orders.

Methods

We conducted a 12-month stepped wedge cluster randomised trial among 45 primary care physicians and advanced practice providers in six adult primary care clinics of a US community group practice.Clinicians were invited to precommit to Choosing Wisely recommendations against imaging for uncomplicated low back pain, imaging for uncomplicated headaches and unnecessary antibiotics for acute sinusitis. Clinicians who precommitted received 1–6 months of point-of-care precommitment reminders as well as patient education handouts and weekly emails with resources to support communication about low-value services.The primary outcome was the difference between control and intervention period percentages of visits with potentially low-value orders. Secondary outcomes were differences between control and intervention period percentages of visits with possible alternate orders, and differences between control and 3-month postintervention follow-up period percentages of visits with potentially low-value orders.

Results

The intervention was not associated with a change in the percentage of visits with potentially low-value orders overall, for headaches or for acute sinusitis, but was associated with a 1.7% overall increase in alternate orders (p=0.01). For low back pain, the intervention was associated with a 1.2% decrease in the percentage of visits with potentially low-value orders (p=0.001) and a 1.9% increase in the percentage of visits with alternate orders (p=0.007). No changes were sustained in follow-up.

Conclusion

Clinician precommitment to follow Choosing Wisely recommendations was associated with a small, unsustained decrease in potentially low-value orders for only one of three targeted conditions and may have increased alternate orders.

Trial registration number

NCT02247050; Pre-results.

Developing High-Functioning Teams: Factors Associated With Operating as a "Real Team" and Implications for Patient-Centered Medical Home Development

Team-based care is a foundation of health care redesign models like the patient-centered medical home (PCMH). Yet few practices rigorously examine how the implementation of PCMH relates to teamwork. We identified factors associated with the perception of a practice operating as a real team. An online workforce survey was conducted with all staff of 12 primary care sites of Cambridge Health Alliance at different stages of PCMH transformation. Bivariate and multivariate analyses of factors associated with teamwork perceptions were conducted. In multivariate models, having effective leadership was the main factor associated with practice teamwork perceptions (odds ratio [OR], 10.49; 95% confidence interval [CI], 5.39-20.43); in addition, practicing at a site in an intermediate stage of PCMH transformation was also associated with enhanced team perceptions (OR, 2.44; 95% CI, 1.28-4.64). In a model excluding effective leadership, respondents at sites in an intermediate stage of PCMH transformation (OR, 1.95; 95% CI, 1.1-3.4) and who had higher care team behaviors (such as huddles and weekly meetings; OR, 3.41; 95% CI, 1.30-8.92), higher care team perceptions (OR, 2.65; 95% CI, 1.15-6.11), and higher job satisfaction (OR, 2.00; 95% CI, 1.02-3.92) had higher practice teamwork perceptions. This study highlights the strong association between effective leadership, care team behaviors and perceptions, and job satisfaction with perceptions that practices operate as real teams. Although we cannot infer causality with these cross-sectional data, this study raises the possibility that providing attention to these factors may be important in augmenting practice teamwork perceptions.

Lower Rates of Promotion of Generalists in Academic Medicine: A Follow-up to the National Faculty Survey

BACKGROUND

Prior cross-sectional research has found that generalists have lower rates of academic advancement than specialists and basic science faculty.

OBJECTIVE

Our objective was to examine generalists relative to other medical faculty in advancement and academic productivity.

DESIGN

In 2012, we conducted a follow-up survey (n = 607) of 1214 participants in the 1995 National Faculty Survey cohort and supplemented survey responses with publicly available data.

PARTICIPANTS

Participants were randomly selected faculty from 24 US medical schools, oversampling for generalists, underrepresented minorities, and senior women.

MAIN MEASURES

The primary outcomes were (1) promotion to full professor and (2) productivity, as indicated by mean number of peer-reviewed publications, and federal grant support in the prior 2 years. When comparing generalists with medical specialists, surgical specialists, and basic scientists on these outcomes, we adjusted for gender, race/ethnicity, effort distribution, parental and marital status, retention in academic career, and years in academia. When modeling promotion to full professor, we also adjusted for publications.

KEY RESULTS

In the intervening 17 years, generalists were least likely to have become full professors (53%) compared with medical specialists (67%), surgeons (66%), and basic scientists (78%, p < 0.0001). Generalists had a lower number of publications (mean = 44) than other faculty [medical specialists (56), surgeons (57), and basic scientists (83), p < 0.0001]. In the prior 2 years, generalists were as likely to receive federal grant funding (26%) as medical (21%) and surgical specialists (21%), but less likely than basic scientists (51%, p < 0.0001). In multivariable analyses, generalists were less likely to be promoted to full professor; however, there were no differences in promotion between groups when including publications as a covariate.

CONCLUSIONS

Between 1995 and 2012, generalists were less likely to be promoted than other academic faculty; this difference in advancement appears to be related to their lower rate of publication.

Is a Positive Developmental-Behavioral Screening Score Sufficient to Justify Referral? A Review of Evidence and Theory

In their recommendations on screening for autism and developmental disabilities, the American Academy of Pediatrics recommends referral subsequent to a positive screening result. In this article, we argue that positive screening results are not always sufficient to justify a referral. We show that although positive predictive values are often low, they actually overstate the probability of having a disorder for many children who screen positive. Moreover, recommended screening thresholds are seldom set to ensure that the benefits of referral will equal or exceed the costs and risk of harm, which is a necessary condition for an optimal threshold in decision analysis. Drawing on recent recommendations for the Institute of Medicine/National Academy of Medicine, we discuss the implications of this argument for pediatric policy, education, and practice. In particular, we recommend that screening policies be revised to ensure that the costs and benefits of actions recommended in the event of a positive screen are appropriate to the screening threshold. We recommend greater focus on clinical decision-making in the education of physicians, including shared decision-making with patients and their families. Finally, we recommend broadening the scope of screening research to encompass not only the accuracy of specific screening instruments, but also their ability to improve decision-making in the context of systems of care.

Impact of a scribe program on patient throughput, physician productivity, and patient satisfaction in a community-based emergency department

Previous literature on the impact of scribe programs varies and has mostly been reported from academic institutions or other clinics. We report the implementation of the scribe program in the emergency room of a community hospital and its impact on patient throughput, physician productivity, and patient satisfaction. We performed a quasi-experimental, before-and-after study measuring patient throughput metrics, physician productivity, and patient satisfaction. The intervention measuring the scribe implementation was divided into pre- and post-implementation periods. Patient throughput metrics were (1) door-to-room time, (2) room-to-doc time, (3) door-to-doc time, (4) doc-to-disposition time, and (5) length of stay for discharged/admitted patients. Our secondary outcome was physician productivity, which was calculated by measuring total patients seen per hour and work relative value units per hour. Additionally, we calculated the time-motion analysis in minutes to measure the emergency department physician’s efficiency by recording the following: (1) chart preparation, (2) chart review, (3) doctor–patient interaction, (4) physical examination, and (5) post-visit documentation. Finally, we measured patient satisfaction as provided by Press Ganey surveys. Data analysis was conducted in 12,721 patient encounters in the pre-scribe cohort, and 13,598 patient encounters in the post-scribe cohort. All the patient throughput metrics were statistically significant (p < 0.0001). The patients per hour increased from 2.3 ± 0.3 pre-scribe to 3.2 ± 0.6 post-scribe cohorts (p < 0.001). Total work relative value units per hour increased from 241(3.1 ± 1.5 per hour) pre-scribe cohort to 336 (5.2 ± 1.4 per hour) post-scribe cohort (p < 0.001). The pre-scribe patient satisfaction was high and remained high in the post-scribe cohort. There was a significant increase in the clinician providing satisfactory feedback from the pre-scribe (3.9 ± 0.3) to the post-scribe (4.7 ± 0.1) cohorts (p < 0.01). We describe a prospective trial of medical scribe use in the emergency department setting to improve patient throughput, physician productivity, and patient satisfaction. We illustrate that scribe use in community emergency department is feasible and results in improvement in all three metrics

Impact of a scribe program on patient throughput, physician productivity, and patient satisfaction in a community-based emergency department

Previous literature on the impact of scribe programs varies and has mostly been reported from academic institutions or other clinics. We report the implementation of the scribe program in the emergency room of a community hospital and its impact on patient throughput, physician productivity, and patient satisfaction. We performed a quasi-experimental, before-and-after study measuring patient throughput metrics, physician productivity, and patient satisfaction. The intervention measuring the scribe implementation was divided into pre- and post-implementation periods. Patient throughput metrics were (1) door-to-room time, (2) room-to-doc time, (3) door-to-doc time, (4) doc-to-disposition time, and (5) length of stay for discharged/admitted patients. Our secondary outcome was physician productivity, which was calculated by measuring total patients seen per hour and work relative value units per hour. Additionally, we calculated the time-motion analysis in minutes to measure the emergency department physician's efficiency by recording the following: (1) chart preparation, (2) chart review, (3) doctor-patient interaction, (4) physical examination, and (5) post-visit documentation. Finally, we measured patient satisfaction as provided by Press Ganey surveys. Data analysis was conducted in 12,721 patient encounters in the pre-scribe cohort, and 13,598 patient encounters in the post-scribe cohort. All the patient throughput metrics were statistically significant (p < 0.0001). The patients per hour increased from 2.3 ± 0.3 pre-scribe to 3.2 ± 0.6 post-scribe cohorts (p < 0.001). Total work relative value units per hour increased from 241(3.1 ± 1.5 per hour) pre-scribe cohort to 336 (5.2 ± 1.4 per hour) post-scribe cohort (p < 0.001). The pre-scribe patient satisfaction was high and remained high in the post-scribe cohort. There was a significant increase in the clinician providing satisfactory feedback from the pre-scribe (3.9 ± 0.3) to the post-scribe (4.7 ± 0.1) cohorts (p < 0.01). We describe a prospective trial of medical scribe use in the emergency department setting to improve patient throughput, physician productivity, and patient satisfaction. We illustrate that scribe use in community emergency department is feasible and results in improvement in all three metrics.

Perceived Barriers to Implementing Individual Choosing Wisely® Recommendations in Two National Surveys of Primary Care Providers

BACKGROUND

While some research has examined general attitudes about efforts to reduce overutilization of services, such as the Choosing Wisely^® (CW) initiative, little data exists regarding primary care providers' attitudes regarding individual recommendations.

OBJECTIVE

We sought to identify whether particular CW recommendations were perceived by primary care providers as difficult to follow, difficult for patients to accept, or both.

DESIGN

Two national surveys, one by mail to a random sample of 2000 U.S. primary care physicians in November 2013, and the second electronically to a random sample of 2500 VA primary care providers (PCPs) in October-December 2014.

PARTICIPANTS

A total of 603 U.S. primary care physicians and 1173 VA primary care providers. Response rates were 34 and 48 %, respectively.

MAIN MEASURES

PCP ratings of whether 12 CW recommendations for screening, testing and treatments applicable to adult primary care were difficult to follow and difficult for patients to accept; and ratings of potential barriers to reducing overutilization.

KEY RESULTS

For four recommendations regarding not screening or testing in asymptomatic patients, less than 20 % of PCPs found the CW recommendations difficult to accept (range 7.2-16.6 %) or difficult for patients to follow (12.2-19.3 %). For five recommendations regarding testing or treatment for symptomatic conditions, however, there was both variation in reported difficulty to follow (9.8-32 %) and a high level of reported difficulty for patients to accept (35.7-87.1 %). The most frequently reported barriers to reducing overuse included malpractice concern, patient requests for services, lack of time for shared decision making, and the number of tests recommended by specialists.

CONCLUSIONS

While PCPs found many CW recommendations easy to follow, they felt that some, especially those for symptomatic conditions, would be difficult for patients to accept. Overcoming PCPs' perceptions of patient acceptability will require approaches beyond routine physician education, feedback and financial incentives.

Medicare annual preventive care visits: use increased among fee-for-service patients, but many do not participate

Under the Affordable Care Act (ACA), Medicare coverage expanded in 2011 to fully cover annual preventive care visits. We assessed the impact of coverage expansion, using 2007-13 data from primary care patients of Medicare-eligible age at the Palo Alto Medical Foundation (204,388 patient-years), which serves people in four counties near San Francisco, California. We compared trends in preventive visits and recommended preventive services among Medicare fee-for-service and Medicare health maintenance organization (HMO) patients as well as non-Medicare patients ages 65-75 who were covered by private fee-for-service and private HMO plans. Among Medicare fee-for-service patients, the annual use of preventive visits rose from 1.4 percent before the implementation of the ACA to 27.5 percent afterward. This increase was significantly larger than was seen for patients in the other insurance groups. Nevertheless, rates of annual preventive care visit use among Medicare fee-for-service patients remained 10-20 percentage points lower than was the case for people with private coverage (43-44 percent) or those in a Medicare HMO (53 percent). ACA policy changes led to increased preventive service use by Medicare fee-for-service beneficiaries, which suggests that Medicare coverage expansion is an effective way to increase seniors' use of preventive services.

Physician Response to Contextualized Price-Comparison Claims in Prescription Drug Advertising

Background

Physician-targeted prescription drug advertisements sometimes include price comparisons between products that may misleadingly imply equivalence of efficacy and safety or misrepresent true savings, suggesting the potential utility of a context statement to explain what the claims do and do not mean.

Methods

We manipulated the presence of a price claim and a context statement in a 1 × 3 (control condition, price-comparison-only, price-comparison-plus-context) between-subjects design. Physicians (N = 1,438), randomly assigned to condition, viewed the prescription drug ad and answered a brief survey. Primary outcome measures included recognition, perceived importance, and impact of the price-comparison claim, and recognition, understanding, and effectiveness of the context statement.

Results

The majority of physicians accurately recognized the price claim (76.0%) but far fewer accurately recognized the associated context statement (44.9%). The context statement did not affect evaluations of the price-comparison claim importance or accuracy and did not have the intended effects on perceptions of uncertainty about drug interchangeability. Physicians may be affected by price-comparison claims in thinking that the drug has risks that are relatively less severe. Price-comparison claims also affected intentions to look for information about the drug.

Conclusions

Adding a realistic context statement to a physician-targeted prescription drug ad did not generate sufficient awareness of claim caveats to differentiate price-comparison response of those exposed to the context statement from those who were not.

Predicting blood pressure outcomes using single-item physician-administered measures: a retrospective pooled analysis of observational studies in Belgium

BACKGROUND

Patient adherence is often not monitored because existing methods of evaluating adherence are either burdensome or do not accurately predict treatment outcomes.

AIM

To examine whether two simple, single-item physician-administered measures of patient adherence to antihypertensive medication are predictive of blood pressure outcomes.

DESIGN AND SETTING

Retrospective database analysis of patients with hypertension treated in Belgian primary care.

METHOD

Using pooled data from five observational studies, a sample was identified of 9725 patients who were assessed using two single-item physician-administered measures of adherence to antihypertensive medication: the first item of the Basel Assessment of Adherence Scale (BAAS) and the Visual Analogue Scale (VAS). These two assessment tools were administered by GPs during regular appointments with patients. Systolic blood pressure (SBP), diastolic blood pressure (DBP), and combined SBP/DBP were measured at baseline and at 90 days.

RESULTS

BAAS-identified adherent patients achieved lower mean SBP and DBP compared with non-adherent patients at 90 days (P<0.001), and had odds ratios of achieving blood pressure control of 0.66 (95% confidence intervals (CI) = 0.61 to 0.73, P<0.001) for SBP, 0.69 (95% CI = 0.62 to 0.76, P<0.001) for DBP, and 0.65 (95% CI = 0.59 to 0.72, P<0.001) for combined SBP/DBP. For VAS-identified adherent patients, the odds ratios of achieving blood pressure control were 0.93 (95% CI = 0.86 to 1.00, P<0.001) for SBP, 0.79 (95% CI = 0.73 to 0.85, P<0.001) for DBP, and 0.91 (95% CI = 0.84 to 0.99, P<0.001) for combined SBP/DBP.

CONCLUSIONS

The first item of the BAAS and the VAS are independent predictors of blood pressure control. These methods can be integrated seamlessly into routine clinical practice by allowing GPs to quickly evaluate a patient's adherence and tailor treatment recommendations accordingly.

The map is not the territory: medical records and 21st century practice

Documentation of care is at risk of overtaking the delivery of care in terms of time, clinician focus, and perceived importance. The medical record as currently used for documentation contributes to increased cognitive workload, strained clinician-patient relationships, and burnout. We posit that a near verbatim transcript of the clinical encounter is neither feasible nor desirable, and that attempts to produce this exact recording are harmful to patients, clinicians, and the health system. In this Viewpoint, we focus on the alternative constructions of the medical record to bring them back to their primary purpose-to aid cognition, communicate, create a succinct account of care, and support longitudinal comprehensive care-thereby to support the building of relationships and medical decision making while decreasing workload.

Physician empowerment programme; a unique workshop for physician-managers of community clinics

BACKGROUND

The physician manager role in the health care system is invaluable as they serve as role models and quality setters. The requirements from physician managers have become more demanding and the role less prestigious; yet burnout and its prevention in this group have received little attention. Physician leadership development programmes have generally dealt directly with skill and knowledge acquisition. The aim of this research was to evaluate an intensive workshop designed to modify attitudes and improve skills of physician-managers of community clinics, through focus on personal well-being and empowerment.

METHODS

Two hundred fifty six physicians affiliated with Clalit Health Services, the largest health maintenance organization in Israel, participated in 16 IMPACT courses during the years 2013-2015. The programme comprised five full days during a two-week period, including an overnight and follow-up meetings three and six weeks later. Theoretical knowledge, experiential learning, practical tools, deep personal exercises, and simulations were conveyed through individual and group work. Topics included: models of self-awareness, outcome thinking, determining a personal and organizational vision, and creating a personal approach to leadership. At the end of each course, and by email at 6 or more months after completion of the course, participants were asked to anonymously respond to closed questions (on a scale of 1-6) and an open question.

RESULTS

Mean scores for the contribution of IMPACT to participants' role of physician manager were 5.3 at the end of the course, and 4.7 at 6 or more months later. Mean scores at 6 or more months were 5.0 regarding the contribution of the programme to personal development, 4.4 regarding satisfaction in the role of physician manager, and 4.6 regarding their coping with managerial dilemmas.

CONCLUSION

A workshop that focused on personal growth and self-awareness increased physicians' job satisfaction and their sense of managerial capability, coping with managerial dilemmas, and belonging to the organization.

Marketing a Radiology Practice

In addition to being a profession, the practice of radiology is a business, and marketing is an important part of that business. There are many facets to marketing a radiology practice. The authors present a number of ideas on how to go about doing this. Some marketing methods can be directed to both patients and referring physicians. Others should be directed just to patients, while still others should be directed just to referring physicians. Aside from marketing, many of them provide value to both target audiences.

COPD Overdiagnosis, Underdiagnosis, and Treatment

This article serves as a CME-available enduring material summary of the following COPD9_USA presentations: - "Spirometry Isn't for Screening - So What Is?" Presenter: David H. Au, MD, MS - "Diagnosis of COPD in a Primary Care Midwest Practice" Presenter: Barbara Yawn, MD, MSc - "What Happens in Primary Care Without Screening?" Presenter: Sandra G. Adams, MD, MS - "From Screening to Diagnosis to Management in a Busy Primary Care Practice"Presenter: Min Joo, MD - "Practical Considerations of How Phenotype and Genotype Can Affect Management Decisions" Presenter: Bartolome Celli, MD.