The impact of improving access to primary care

Impact of early primary care physician follow-up on hospital readmission following gastrointestinal cancer surgery

BACKGROUND

We sought to examine the association between primary care physician (PCP) follow-up on readmission following gastrointestinal (GI) cancer surgery.

METHODS

Patients who underwent surgery for GI cancer were identified using the Surveillance, Epidemiology and End Results (SEER) database. Multivariable regression was performed to examine the association between early PCP follow-up and hospital readmission.

RESULTS

Among 60 957 patients who underwent GI cancer surgery, 19 661 (32.7%) visited a PCP within 30-days after discharge. Of note, patients who visited PCP were less likely to be readmitted within 90 days (PCP visit: 17.4% vs. no PCP visit: 28.2%; p < 0.001). Median postsurgical expenditures were lower among patients who visited a PCP (PCP visit: $4116 [IQR: $670-$13 860] vs. no PCP visit: $6700 [IQR: $870-$21 301]; p < 0.001). On multivariable analysis, PCP follow-up was associated with lower odds of 90-day readmission (OR: 0.52, 95% CI: 0.50-0.55) (both p < 0.001). Moreover, patients who followed up with a PCP had lower risk of death at 90-days (HR: 0.50, 95% CI: 0.40-0.51; p < 0.001).

CONCLUSION

PCP follow-up was associated with a reduced risk of readmission and mortality following GI cancer surgery. Care coordination across in-hospital and community-based health platforms is critical to achieve optimal outcomes for patients.

Factors associated with frequent emergency department visits among health centre patients receiving primary care

RATIONALE, AIMS AND OBJECTIVES

We sought to examine specific care-seeking behaviours and experiences, access indicators, and patient care management approaches associated with frequency of emergency department (ED) visits among patients of Health Resources and Services Administration-funded health centres that provide comprehensive primary care to low-income and uninsured patients.

METHOD

We used cross-sectional data of a most recent nationally representative sample of health centre adult patients aged 18-64 (n = 4577) conducted between October 2014 and April 2015. These data were merged with the 2014 Uniform Data System to incorporate health centre characteristics. We measured care-seeking behaviours by whether the patient called the health centre afterhours, for an urgent appointment, or talked to a provider about a concern. Access to care indicators included health centre continuity of care and receipt of transportation or translation services. We included receipt of care coordination and specialist referral as care management indicators. We used a multilevel multinomial logistic regression model to identify the association of independent variables with number of ED visits (4 or more visits, 2-3 visits, 1 visit, vs. 0 visits), controlling for predisposing, enabling, and need characteristics.

RESULTS

Calling the health centre after-hours (OR = 2.41) or for urgent care (OR = 2.53), and being referred to specialists (OR = 2.36) were associated with higher odds of four or more ED visits versus none. Three or more years of continuity with the health centre (OR = 0.32) was also associated with lower odds of four or more ED visits versus none.

CONCLUSIONS

Findings underscore opportunities to reduce higher frequency of ED visits in health centres, which are primary care providers to many low-income populations. Our findings highlight the potential importance of improving patient retention, better access to providers afterhours or for urgent visits, and access to specialist as areas of care in need of improvement.

Potential Factors Associated with Healthcare Utilization for Balance Problems in Community-Dwelling Adults within the United States: A Narrative Review

Falls are the leading cause of mortality and chronic disability in elderly adults. There are effective fall prevention interventions available. But only a fraction of the individuals with balance/dizziness problems are seeking timely help from the healthcare system. Current literature confirms the underutilization of healthcare services for the management of balance problems in adults, especially older adults. This review article explores factors associated with healthcare utilization as guided by the Andersen Healthcare Utilization Model, a framework frequently used to explore the factors leading to the use of health services. Age, sex, race/ethnicity, BMI, and comorbidities have been identified as some of the potential predisposing factors; socioeconomic status, health insurance, and access to primary care are the enabling and disabling factors; and severity of balance problem, perceived illness, and its impact on daily activities are the factors affecting need for care associated with healthcare utilization for balance or dizziness problems. Knowledge about these barriers can help direct efforts towards improved screening of vulnerable individuals, better access to care, and education regarding effective fall prevention interventions for those who are at risk for underutilization. This can aid in timely identification and management of balance problems, thereby reducing the incidence of falls.

Weight Loss in a Digital Diabetes Prevention Program for People in Health Professional Shortage and Rural Areas

Individuals with prediabetes living in hard-to-reach and underserved areas experience barriers to accessing traditional in-person preventive health services. The National Diabetes Prevention Program (DPP) is a preventive health care program designed to reduce the risk of developing type 2 diabetes. Although there have been increasing numbers of remote DPPs accessible, there are little data on the clinical outcomes of digital DPPs for members living in hard-to-reach and underserved areas. This study assessed whether living in a designated Health Professional Shortage Area (HPSA) and a rural versus urban area impacted the weight loss of N = 7266 members of a fully digital program called Lark DPP. Secondary analyses included between-group comparisons of program retention and member characteristics, demographics, and socioeconomics. Percent weight loss did not differ by HPSA (P = 0.16) or rural/urban status (P = 0.15), despite greater potential barriers for members residing in HPSAs (eg, highest starting body mass index, lowest income, lowest education). Mean percent weight loss for members residing in an HPSA and rural area was mean (M) = 4.75%, standard error (SE) = 0.09; for members in a non-HPSA, rural area M = 4.96%, SE = 0.16; for members in an HPSA, urban area M = 4.55%, SE = 0.13; and for members in a non-HPSA, urban area M = 4.77%, SE = 0.13. Members of a fully digital DPP achieved weight loss that did not differ by HPSA or urban/rural designation. Fully digital programs offer a solution to reduce the risk of type 2 diabetes in areas where residents may not otherwise have access to diabetes prevention services.

Primary Health Care: Our Experience From an Urban Primary Health Care Center in Greece

This observational study reported patient data derived from the emergency files of a primary health care (PHC) center in Greece, with the aim of providing potential solutions for a well-organized, well-structured, and effective social healthcare system. This series was conducted at a single urban PHC center in Greece between August 2017 and March 2020. A total of 83,592 patient visits were registered. The mean patient age was 42.5 years (range: three months to 93 years). Demographics, presenting complaints, and the need for patients who visited the healthcare center to be referred to tertiary hospitals were examined. Further perspectives and future strategies to strengthen the national PHC system were addressed. The most common reasons for visits were pathological (33.6%), followed by general surgery (21.2%) and orthopedics (18.1%). Pediatric conditions accounted for 12% of visits, cardiological conditions accounted for 8.6%, and dental problems accounted for 6.8%. The majority of the patients (n = 81,317, 97.3%) were managed within the health center, and only 2.7% of cases (n = 2275) needed to be referred to a secondary or tertiary healthcare structure. Reasons for patient referral included the severity or complexity of the patient's situation, lack of a specific medical specialty, and the unavailability of overnight laboratory tests. The PHC center remains the cornerstone of a high-quality healthcare system. A well-structured PHC unit can improve health outcomes and decongest secondary and tertiary health care.

Organization of primary care

Strong primary care does not develop spontaneously but requires a well-developed organizational planning between levels of care. Primary care-oriented health systems are required to effectively tackle unmet health needs of the population, and efficient primary care organization (PCO) is crucial for this aim. Via strong primary care, health delivery, health outcomes, equity, and health security could be improved. There are several theoretical models on how primary care can be organized. In this position paper, the key aspects and benchmarks of PCO will be explored based on previously mentioned frameworks and domains. The aim of this position paper is to assist primary care providers, policymakers, and researchers by discussing the current context of PCO and providing guidance for implementation, development, and evaluation of it in a particular setting. The conceptual map of this paper consists of structural and process (PC service organization) domains and is adapted from frameworks described in literature and World Health Organization resources. Evidence we have gathered for this paper shows that for establishing a strong PCO, it is crucial to ensure accessible, continuous, person-centered, community-oriented, coordinated, and integrated primary care services provided by competent and socially accountable multiprofessional teams working in a setting where clear policy documents exist, adequate funding is available, and primary care is managed by dedicated units.

Association of Primary Care Shortage Areas with Adverse Outcomes after Pediatric Liver Transplant

OBJECTIVE

To characterize associations between living in primary care shortage areas and graft failure/death for children after liver transplantation.

STUDY DESIGN

This was an observational study of all pediatric patients (aged <19 years) who received a liver transplant between January 1, 2005, and December 31, 2015 in the US, with follow-up through January 2019 (N = 5964). One hundred ninety-five patients whose home ZIP code could not be matched to primary care shortage area status were excluded. The primary outcome was a composite endpoint of graft failure or death. We used Cox proportional hazards to model the associations between health professional shortage area (HPSA) and graft failure/death.

RESULTS

Children living in HPSAs had lower estimated graft survival rates at 10 years compared with those not in HPSAs (76% vs 80%; P < .001). In univariable analysis, residence in an HPSA was associated with a 22% higher hazard of graft failure/death than non-residence in an HPSA (hazard ratio [HR], 1.22; 95% CI, 1.09-1.36; P < .001). Black children from HPSAs had a 67% higher hazard of graft failure/death compared with those not in HPSAs (HR, 1.67; 95% CI, 1.29 to 2.16; P = .006); the effect of HPSA status was less pronounced for White children (HR, 1.11; 95% CI, 0.98-1.27; P = .10).

CONCLUSIONS

Children living in primary care shortage areas are at increased risk of graft failure and death after liver transplant, and this risk is particularly salient for Black children. Future work to understand how living in these regions contributes to adverse outcomes may enable teams to mitigate this risk for all children with chronic illness.

Advancing multimorbidity management in primary care: a narrative review

BACKGROUND

Multimorbidity, defined as the coexistence of two or more chronic conditions in the same individual, is becoming a crucial health issue in primary care. Patients with multimorbidity utilize health care at a higher rate and have higher mortality rates and poorer quality of life compared to patients with single diseases.

AIMS

To explore evidence on how to advance multimorbidity management, with a focus on primary care. Primary care is where a large number of patients with multimorbidity are managed and is considered to be a gatekeeper in many health systems.

METHODS

A narrative review was conducted using four major electronic databases consisting of PubMed, Cochrane, World Health Organization database, and Google scholar. In the first round of reviews, priority was given to review papers summarizing the current issues and challenges in the management of multimorbidity. Thematic analysis using an inductive approach was used to build a framework on how to advance management. The second round of review focused on original articles providing evidence within the primary care context.

RESULTS

The review found that advancing multimorbidity management in primary care requires a health system approach and a patient-centered approach. The health systems approach includes three major areas: (i) improves access to care, (ii) promotes generalism, and (iii) provides a decision support system. For the patient-centered approach, four key aspects are essential for multimorbidity management: (i) promoting doctor-patient relationship, (ii) prioritizing health problems and sharing decision-making, (iii) supporting self-management, and (iv) integrating care.Advancement of multimorbidity management in primary care requires integrating concepts of multimorbidity management guidelines with concepts of patient-centered and chronic care models. This simple integration provides an overarching framework for advancing the health care system, connecting the processes of individualized care plans, and integrating care with other providers, family members, and the community.

A realist synthesis of staff-based primary health care interventions addressing universal health coverage

Background

Methods

Results

Conclusions

Employer-Led Strategies to Improve the Value of Health Spending: A Systematic Review

OBJECTIVE

To systematically review studies that evaluated the impact of employer-led efforts in the United States to improve the value of health spending, where employers have implemented changes to their health benefits to reduce costs while improving or maintaining quality.

METHODS

We included all studies of employer-led health benefit strategies that reported outcomes for both employer health spending and employee health outcomes.

RESULTS

Our search returned 44 studies of employer health benefit changes that included measures of both health spending and quality. The most promising efforts were those that lowered or eliminated cost sharing for primary care or medications for chronic illnesses. High deductible health plans with a savings option appeared less promising.

CONCLUSIONS

More research is needed on the characteristics and contexts in which these benefit changes were implemented, and on actions that address employers' current concerns.

What explains the inequalities in health care utilization between immigrants and non-migrants in Switzerland?

BACKGROUND

Inequalities in health care use between immigrants and non-migrants are an important issue in many countries, with potentially negative effects on population health and welfare. The aim of this study is to understand the factors that explain these inequalities in Switzerland, a country with one of the highest percentages of foreign-born population.

METHODS

Using health survey data, we compare non-migrants to four immigrant groups, differentiating between first- and second-generation immigrants, and culturally different and similar immigrants. To retrieve the relative contribution of each inequality-associated factor, we apply a non-linear decomposition method and categorize the factors into demographic, socio-economic, health insurance and health status factors.

RESULTS

We find that non-migrants are more likely to visit a doctor compared to first-generation and culturally different immigrants and are less likely to visit the emergency department. Inequalities in doctor visits are mainly attributed to the explained component, namely to socio-economic factors (such as occupation and income), while inequalities in emergency visits are mainly attributed to the unexplained component. We also find that despite the universal health care coverage in Switzerland systemic barriers might exist.

CONCLUSIONS

Our results indicate that immigrant-specific policies should be developed in order to improve access to care and efficiently manage patients in the health system.

Healthcare outcomes for patients with type 2 diabetes with and without comorbid obesity

AIMS

Examine the burden of comorbid obesity associated with type 2 diabetes (T2D).

METHODS

The IBM® MarketScan® Explorys Claims Electronic Medical Records Data were used to identify adults with T2D, two recorded body mass index (BMI) values, and continuous insurance coverage from 1 year prior through 1 year post index date. Patients with index BMI ≥18 kg/m² and <30 kg/m² (normal/overweight) were matched to patients with index BMI ≥ 30 kg/m² (obese) using propensity score matching (PSM). Using the PSM cohort, multivariable analyses examined the association between obesity and patient comorbidities, healthcare costs, and resource utilization.

RESULTS

In the matched cohort (16,006 normal/overweight; 16,006 obese), multivariable analyses showed that obesity, compared to normal/overweight, was associated with increased odds of a diabetes-related comorbidity (Odds Ratio [OR] = 1.29; 95% Confidence Interval [CI] 1.21-1.38) and an obesity-related comorbidity (OR = 1.42; 95% CI 1.29-1.56). Obesity was also associated with significantly higher annual diabetes-related and all-cause total costs and resource utilization.

CONCLUSIONS

This research increases the knowledge of how patients with T2D and obesity should be of greater concern for healthcare providers compared to T2D patients without comorbid obesity, given their worse comorbidity profile, increased resource utilization, and higher healthcare costs.

Can primary care access reduce health care utilization for patients with obesity-associated chronic conditions in medically underserved areas?

OBJECTIVES

The prevalence and burdens of obesity-associated chronic conditions (OCC) are rising nationwide, particularly in health professional shortage areas (HPSA). This study examined the impact of access to primary care on health care utilization for vulnerable populations with OCC in the South.

METHODS

Adult patients with obesity (BMI ≥ 30 kg/m² ), greater than or equal to one additional OCC, and self-reported primary care access data were retrospectively identified from hospital and emergency department (ED) electronic medical records of a major health care system in the South. Multivariable logistic regression assessed factors associated with self-reported access to primary care. Multivariable zero-inflated negative binomial models assessed effect of HPSA residence on relationships between self-reported access to primary care and health care utilization.

RESULTS

A total of 29 674 patients were identified. Hypertension (76.1%), type 2 diabetes mellitus (34.1%), and hyperlipidemia (32.9%) were the most prevalent OCC. Males (odds ratio [OR]: 0.43; 95% confidence interval [CI], 0.40-0.47), unmarried (OR: 0.69; 95% CI, 0.63-0.76), and uninsured (OR: 0.29; 95% CI, 0.27-0.32) had lower odds of access to primary care. For patients living in HPSA (vs non-HPSA), access to primary care was associated with higher incidence of overall ED use (relative risk [RR]: 1.38; 95% CI, 1.19-1.61) and lower incidence of potentially preventable hospital use (RR: 0.59; 95% CI, 0.38-0.92).

CONCLUSION

Paradoxically, access to primary care may increase ED use while reducing potentially preventable hospital utilization for patients with OCC in HPSA. Increasing access to primary care alone, without strengthening its capacity to serve the needs of vulnerable patients, may be insufficient to reduce hospital utilization.

A Veterans Affairs Primary Care Same-Day Open Access for New Patients Optimized Redesigned System (VA-HONORS): A Six-Year Analysis of 22,220 Patient Records

BACKGROUND

Delay in primary care access for new patients to US Department of Veterans Affairs (VA) health care services has been a persistent problem. This article presents the evaluation of a quality improvement (QI) intervention that provided new patients with same-day primary care access. It involved redesign of an intake clinic (IC) through which new patients were initially seen and referred to primary care. The redesign included changes in clinic flow and reallocation of two full-time primary care providers (PCPs) from IC to their primary care teams.

METHODS

A pre-post retrospective study evaluating a QI intervention at a VA hospital examined 22,220 administrative patient records. Specifically, 9,909 new patients seen in the three years prior to implementation of VA-HONORS (preintervention group) were compared with 12,311 patients seen in the three years after implementation (postintervention group). Study outcomes were (1) number of days to first appointment with PCP, (2) proportion of patients receiving same-day primary care access, and (3) visit cycle time.

RESULTS

Preintervention, median first primary care appointment delay was 96 days, compared to 0 days postintervention (p < 0.001). Preintervention, 3.1% of new patients were able to obtain same-day primary care appointment, compared with 91.5% postintervention (p < 0.001). Median visit cycle time was 140 minutes preintervention vs. 148 minutes postintervention (p < 0.001).

CONCLUSIONS

New patients' same-day access system redesign at one VA hospital dramatically eliminated first primary care appointment delay. The redesign was feasible and sustainable for a sizable population and serves as a model for similar settings with new patients' primary care access delay.

Access to primary healthcare services and associated factors in urban slums in Nairobi-Kenya

Background

Access to primary healthcare is crucial for the delivery of Kenya’s universal health coverage policy. However, disparities in healthcare have proved to be the biggest challenge for implementing primary care in poor-urban resource settings. In this study, we assessed the level of access to primary healthcare services and associated factors in urban slums in Nairobi-Kenya.

Methods

The data were drawn from the Lown scholars’ study of 300 randomly selected households in Viwandani slums (Nairobi, Kenya), between June and July 2018. Access to primary care was measured using Penchansky and Thomas’ model. Access index was constructed using principal component analysis and recorded into tertiles with categories labeled as poor, moderate, and highest. Generalized ordinal logistic regression analysis was used to determine the factors associated with access to primary care. The adjusted odds ratios (AOR) and 95% confidence intervals were used to interpret the strength of associations.

Results

The odds of being in the highest access tertile versus the combined categories of lowest and moderate access tertile were three times higher for males than female-headed households (AOR 3.05 [95% CI 1.47–6.37]; p < .05). Households with an average quarterly out-of-pocket healthcare expenditure of ≥USD 30 had significantly lower odds of being in the highest versus combined categories of lowest and moderate access tertile compared to those spending ≤ USD 5 (AOR 0.36 [95% CI 0.18–0.74]; p < .05). Households that sought primary care from private facilities had significantly higher odds of being in the highest versus combined categories of lowest and moderate access tertiles compared to those who sought care from public facilities (AOR 6.64 [95% CI 3.67–12.01]; p < .001).

Conclusion

In Nairobi slums in Kenya, living in a female-headed household, seeking care from a public facility, and paying out-of-pocket for healthcare are significantly associated with low access to primary care. Therefore, the design of the UHC program in this setting should prioritize quality improvement in public health facilities and focus on policies that encourage economic empowerment of female-headed households to improve access to primary healthcare.

The macroeconomic benefits of Tennessee APRNs having full practice authority

BACKGROUND

To-date, advocacy efforts to advance full practice authority for APRNs have primarily stressed arguments based on evidence on the cost effectiveness and quality of APRN-provided care, as well as the improved care access and patient satisfaction these providers offer.

PURPOSE

The economic impact analysis forecasts the additional job and economic output associated with granting Tennessee APRNs full practice authority.

METHODS

The IMPLAN software and a variety of data inputs were used to estimate the direct, indirect, and induced economic impact on jobs, labor income, value-added benefits, total output, and tax revenues.

FINDINGS

From a 2017 baseline, the cumulative impact of granting Tennessee APRNs full practice authority is a net gain of 25,536 jobs and $3.2 billion in economic impact.

DISCUSSION

Granting Tennessee APRNs full practice authority would confer substantial economic benefits and employment opportunities to the state.

Care transitions programs for older adults-a worldwide need

In many countries around the world, including the United States, care for vulnerable older people is fragmented, especially at the time of hospital discharge and in the postacute hospital period. Thus, a major challenge for health care systems is to deliver the right type of post-acute care, in the right setting, by the right health care professionals, and for the right length of time. Care transition programs should avoid unnecessary harm related to poor transfer of care between settings, and address common problems as care transitions occur. In the US, Medicare, the major health insurance for older people, is incentivizing value-based over volume-based care, and financially penalizing hospitals for high 30-day readmission rates. In value-based care programs such as Medicare managed care, accountable care organizations, and bundled payments, effective care transitions programs are financially feasible because they have the potential for substantial cost savings from preventing unnecessary emergency department visits, hospital readmissions, other misuse of resources, and costly complications for patients and their families. In this special article, we provide a brief overview of the challenges of care transitions, and elements of care transitions programs developed and tested in the US that could be adapted to the dynamic, heterogeneous health care system in Europe as well as other countries around the world.

The impact of improving access to primary care

OBJECTIVES

To measure the size and timing of changes in utilization and costs for employees and dependents who had major access barriers to primary care removed, across an 8-year period (2007 to 2014).

STUDY DESIGN AND METHODS

Retrospective observational study examining patterns of utilization and costs before and after the implementation of a worksite medical office in 2010. The worksite office offered convenient primary care services with no travel from work, essentially guaranteed same day access, and no co-pay. Trends in visit rates and costs were compared for an intervention fixed cohort group (employees and dependents) at the employer (n = 1211) with a control fixed cohort group (n = 542 162) for 6 types of visits (primary, urgent, emergency, inpatient, specialty, and other outpatient). Difference-in-differences methods assessed the significance of between-group changes in utilization and costs.

RESULTS

The worksite medical office intervention group had an increase in primary care visits relative to the control group (+43% vs +4%, P < 0.001). This was accompanied by a reduction in urgent care visits by the intervention group compared with the control group (-43% vs -5%, P < 0.001). There were no differences in the other types of visits, and the total visit costs for the intervention group increased 5.7% versus 2.7% for the control group (P = 0.008). A sub-group analysis of the intervention group (comparing dependents to employees) found that that the dependents achieved a reduction in costs of 2.7% (P < 0.001) across the study period.

CONCLUSIONS

The potential for long-term reduction in utilization and costs with better access to primary care is significant, but not easily nor automatically achieved.