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Tran LD, Wagner TH, Shekelle P, Nelson KM, Fihn SD, Newberry S, Ghai I, Curtis I, Rubenstein LV. Assessing and Improving Productivity in Primary Care: Proof of Concept Results for a Novel Value-Based Metric. J Gen Intern Med 2024; 39:2317-2323. [PMID: 38926317 DOI: 10.1007/s11606-024-08710-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 02/27/2024] [Indexed: 06/28/2024]
Affiliation(s)
- Linda Diem Tran
- Health Economics Resource Center, Veterans Affairs Palo Alto Health Care System, Menlo Park, CA, USA.
- Stanford Surgery Policy Improvement and Education Center, Stanford Medicine, Stanford University, Stanford, CA, USA.
| | - Todd H Wagner
- Health Economics Resource Center, Veterans Affairs Palo Alto Health Care System, Menlo Park, CA, USA
- Stanford Surgery Policy Improvement and Education Center, Stanford Medicine, Stanford University, Stanford, CA, USA
| | - Paul Shekelle
- VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
- Division of General Internal Medicine & Health Services Research, Department of Medicine, University of California, Los Angeles (UCLA), Los Angeles, CA, USA
| | - Karin M Nelson
- Department of Medicine, University of Washington, Seattle, WA, USA
- Veterans Affairs Puget Sound Healthcare System, Seattle, WA, USA
| | - Stephan D Fihn
- Department of Medicine, University of Washington, Seattle, WA, USA
- Department of Health Systems and Population Health, University of Washington, Seattle, WA, USA
| | | | - Ishita Ghai
- Pardee RAND Graduate School, RAND Corporation, Santa Monica, CA, USA
| | - Idamay Curtis
- Veterans Affairs Puget Sound Healthcare System, Seattle, WA, USA
| | - Lisa V Rubenstein
- Geffen School of Medicine, University of California, Los Angeles (UCLA), Los Angeles, CA, USA
- Fielding School of Public Health, UCLA, Los Angeles, CA, USA
- RAND Corporation, Santa Monica, CA, USA
- Pardee RAND Graduate School, RAND Corporation, Santa Monica, CA, USA
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Kumari R, Chander S. Improving healthcare quality by unifying the American electronic medical report system: time for change. Egypt Heart J 2024; 76:32. [PMID: 38489094 PMCID: PMC10942963 DOI: 10.1186/s43044-024-00463-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2023] [Accepted: 03/03/2024] [Indexed: 03/17/2024] Open
Abstract
BACKGROUND In recent years, innovation in healthcare technology has significantly improved the efficiency of the healthcare system. Advancements have led to better patient care and more cost-effective services. The electronic medical record (EMR) system, in particular, has enhanced interoperability and collaboration across healthcare departments by facilitating the exchange and utilization of patient data. The COVID-19 pandemic further accelerated this trend, leading to a surge in telemedicine services, which rely on electronic communication to deliver healthcare remotely. MAIN BODY Integrating artificial intelligence (AI) and machine learning (ML) in healthcare have been instrumental in analyzing vast data sets, allowing for identifying patterns and trends that can improve care delivery and pinpoint potential issues. The proposal of a unified EMR system in the USA aims to capitalize on these technological advancements. Such a system would streamline the sharing of patient information among healthcare providers, improve the quality and efficiency of care, and minimize the likelihood of errors in patient treatment. CONCLUSION A unified electronic medical record system represents a promising avenue for enhancing interoperability within the US healthcare sector. By creating a more connected and accessible network of patient information, it sets the stage for a transformation in healthcare delivery. This change is imperative for maintaining the momentum of progress in healthcare technology and realizing the full potential of recent advancements in patient care and system efficiency.
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Affiliation(s)
- Roopa Kumari
- Department of Pathology, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy PI, New York, NY, 10029, USA
| | - Subhash Chander
- Department of Pathology, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy PI, New York, NY, 10029, USA.
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AGGARWAL MONICA, HUTCHISON BRIAN, ABDELHALIM REHAM, BAKER GROSS. Building High-Performing Primary Care Systems: After a Decade of Policy Change, Is Canada "Walking the Talk?". Milbank Q 2023; 101:1139-1190. [PMID: 37743824 PMCID: PMC10726918 DOI: 10.1111/1468-0009.12674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 07/29/2023] [Accepted: 08/15/2023] [Indexed: 09/26/2023] Open
Abstract
Policy Points Considerable investments have been made to build high-performing primary care systems in Canada. However, little is known about the extent to which change has occurred over the last decade with implementing programs and policies across all 13 provincial and territorial jurisdictions. There is significant variation in the degree of implementation of structural features of high-performing primary care systems across Canada. This study provides evidence on the state of primary care reform in Canada and offers insights into the opportunities based on changes that governments elsewhere have made to advance primary care transformation. CONTEXT Despite significant investments to transform primary care, Canada lags behind its peers in providing timely access to regular doctors or places of care, timely access to care, developing interprofessional teams, and communication across health care settings. This study examines changes over the last decade (2012 to 2021) in policies across 13 provincial and territorial jurisdictions that address the structural features of high-performing primary care systems. METHODS A multiple comparative case study approach was used to explore changes in primary care delivery across 13 Canadian jurisdictions. Each case consisted of (1) qualitative interviews with academics, provincial health care leaders, and health care professionals and (2) a literature review of policies and innovations. Data for each case were thematically analyzed within and across cases, using 12 structural features of high-performing primary care systems to describe each case and assess changes over time. FINDINGS The most significant changes include adopting electronic medical records, investments in quality improvement training and support, and developing interprofessional teams. Progress was more limited in implementing primary care governance mechanisms, system coordination, patient enrollment, and payment models. The rate of change was slowest for patient engagement, leadership development, performance measurement, research capacity, and systematic evaluation of innovation. CONCLUSIONS Progress toward building high-performing primary care systems in Canada has been slow and variable, with limited change in the organization and delivery of primary care. Canada's experience can inform innovation internationally by demonstrating how preexisting policy legacies constrain the possibilities for widespread primary care reform, with progress less pronounced in the attributes that impact physician autonomy. To accelerate primary care transformation in Canada and abroad, a national strategy and performance measurement framework is needed based on meaningful engagement of patients and other stakeholders. This must be accompanied by targeted funding investments and building strong data infrastructure for performance measurement to support rigorous research.
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Affiliation(s)
| | - BRIAN HUTCHISON
- Centre for Health Economics and Policy AnalysisMcMaster University
| | - REHAM ABDELHALIM
- Institute of Health PolicyManagement and EvaluationUniversity of Toronto
| | - G. ROSS BAKER
- Dalla Lana School of Public HealthUniversity of Toronto
- Institute of Health PolicyManagement and EvaluationUniversity of Toronto
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Katta R, Strouphauer E, Ibraheim MK, Li-Wang J, Dao H. Practice Efficiency in Dermatology: Enhancing Quality of Care and Physician Well-Being. Cureus 2023; 15:e39195. [PMID: 37378213 PMCID: PMC10292050 DOI: 10.7759/cureus.39195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/18/2023] [Indexed: 06/29/2023] Open
Abstract
A focus on improved efficiency can impact both patient care and physician well-being. Efficiency is one of the six domains of healthcare quality. It is also recognized as one of the three main pillars of professional fulfillment. Quality improvement measures in the area of efficiency are focused on reducing waste, specifically related to physicians' time, energy, and cognitive demands. Interventions and practices reported in the literature or communicated by dermatologists have documented efforts centered on patient care workflows, documentation, communication, and other areas. Team-based care models maximize the skill sets of other trained providers, while workflow changes encompassing process standardization, communication, and task automatization have improved patient safety and efficiency. Strategies to promote documentation efficiency have centered on eliminating extraneous documentation alongside the use of templates, text expander functionality, and dictation tools. The use of in-office or virtual scribes, when provided with adequate training and consistent feedback, has improved charting time, accuracy, and physician satisfaction. Although upfront investments in time and financial resources may be required, quality improvement in efficiency can benefit healthcare quality, patient safety, and physician satisfaction.
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Affiliation(s)
- Rajani Katta
- Internal Medicine, Baylor College of Medicine, Houston, USA
- Dermatology, University of Texas Health Science Center at Houston, Houston, USA
| | | | | | | | - Harry Dao
- Dermatology, Loma Linda University Health, Loma Linda, USA
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Trockel MT, Menon NK, Makowski MS, Wen LY, Roberts R, Bohman BD, Shanafelt TD. IMPACT: Evaluation of a Controlled Organizational Intervention Using Influential Peers to Promote Professional Fulfillment. Mayo Clin Proc 2023; 98:75-87. [PMID: 36464536 DOI: 10.1016/j.mayocp.2022.06.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Revised: 04/15/2022] [Accepted: 06/30/2022] [Indexed: 12/04/2022]
Abstract
OBJECTIVE To determine the effects of a popular opinion leader (POL)-led organizational intervention targeting all physicians and advanced practice providers (APPs) working within clinic groups on professional fulfillment (primary outcome), gratitude, burnout, self-valuation, and turnover intent. PATIENTS AND METHODS All 20 Stanford University HealthCare Alliance clinics with ≥5 physicians-APPs were matched by size and baseline gratitude scores and randomly assigned to immediate or delayed intervention (control). Between July 10, 2018, and March 15, 2019, trained POLs and a physician-PhD study investigator facilitated 4 interactive breakfast or lunch workshops at intervention clinics, where colleagues were invited to discuss and experience one evidence-based practice (gratitude, mindfulness, cognitive, and behavioral strategies). Participants in both groups completed incentivized annual assessments of professional fulfillment, workplace gratitude, burnout, self-valuation, and intent to leave as part of ongoing organizational program evaluation. RESULTS Eighty-four (75%) physicians-APPs at intervention clinics attended at least 1 workshop. Of all physicians-APPs, 236 of 251 (94%) completed assessments in 2018 and 254 of 263 (97%) in 2019. Of 264 physicians-APPs with 2018 or 2019 assessment data, 222 (84%) had completed 2017 assessments. Modal characteristics were 60% female, 46% White, 49% aged 40 to 59 years, 44% practicing family-internal medicine, 78% living with partners, and 53% with children. Change in professional fulfillment by 2019 relative to average 2017 to 2018 levels was more favorable (0.63 points; effect size = 0.35; P=.001) as were changes in gratitude and intent to leave among clinicians practicing at intervention clinics. CONCLUSION Interventions led by respected physicians-APPs can achieve high participation rates and have potential to promote well-being among their colleagues.
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Affiliation(s)
| | - Nikitha K Menon
- Stanford University School of Medicine, Palo Alto, California
| | | | - Louise Y Wen
- Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire
| | - Rachel Roberts
- Stanford University School of Medicine, Palo Alto, California
| | - Bryan D Bohman
- Stanford University School of Medicine, Palo Alto, California
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Escribe C, Eisenstat SA, Palamara K, O'Donnell WJ, Wasfy JH, Del Carmen MG, Lehrhoff SR, Bravard MA, Levi R. Understanding Physician Work and Well-being Through Social Network Modeling Using Electronic Health Record Data: a Cohort Study. J Gen Intern Med 2022; 37:3789-3796. [PMID: 35091916 PMCID: PMC9640486 DOI: 10.1007/s11606-021-07351-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Accepted: 12/15/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND Understanding association between factors related to clinical work environment and well-being can inform strategies to improve physicians' work experience. OBJECTIVE To model and quantify what drivers of work composition, team structure, and dynamics are associated with well-being. DESIGN Utilizing social network modeling, this cohort study of physicians in an academic health center examined inbasket messaging data from 2018 to 2019 to identify work composition, team structure, and dynamics features. Indicators from a survey in 2019 were used as dependent variables to identify factors predictive of well-being. PARTICIPANTS EHR data available for 188 physicians and their care teams from 18 primary care practices; survey data available for 163/188 physicians. MAIN MEASURES Area under the receiver operating characteristic curve (AUC) of logistic regression models to predict well-being dependent variables was assessed out-of-sample. KEY RESULTS The mean AUC of the model for the dependent variables of emotional exhaustion, vigor, and professional fulfillment was, respectively, 0.665 (SD 0.085), 0.700 (SD 0.082), and 0.669 (SD 0.082). Predictors associated with decreased well-being included physician centrality within support team (OR 3.90, 95% CI 1.28-11.97, P=0.01) and share of messages related to scheduling (OR 1.10, 95% CI 1.03-1.17, P=0.003). Predictors associated with increased well-being included higher number of medical assistants within close support team (OR 0.91, 95% CI 0.83-0.99, P=0.05), nurse-centered message writing practices (OR 0.89, 95% CI 0.83-0.95, P=0.001), and share of messages related to ambiguous diagnosis (OR 0.92, 95% CI 0.87-0.98, P=0.01). CONCLUSIONS Through integration of EHR data with social network modeling, the analysis highlights new characteristics of care team structure and dynamics that are associated with physician well-being. This quantitative methodology can be utilized to assess in a refined data-driven way the impact of organizational changes to improve well-being through optimizing team dynamics and work composition.
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Affiliation(s)
- Célia Escribe
- Operations Research Center, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Stephanie A Eisenstat
- Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Kerri Palamara
- Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Walter J O'Donnell
- Harvard Medical School, Boston, MA, USA
- Pulmonary/Critical Care Division, Massachusetts General Hospital, Boston, MA, USA
| | - Jason H Wasfy
- Harvard Medical School, Boston, MA, USA
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Marcela G Del Carmen
- Harvard Medical School, Boston, MA, USA
- Division of Gynecologic Oncology, Massachusetts General Hospital, Boston, MA, USA
| | | | - Marjory A Bravard
- Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Retsef Levi
- Sloan School of Management, Massachusetts Institute of Technology, Cambridge, MA, USA.
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Mohammed HT, Bartlett RL, Babb D, Fraser RDJ, Mannion D. A time motion study of manual versus artificial intelligence methods for wound assessment. PLoS One 2022; 17:e0271742. [PMID: 35901189 PMCID: PMC9333325 DOI: 10.1371/journal.pone.0271742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 07/06/2022] [Indexed: 11/25/2022] Open
Abstract
Objectives This time-motion study explored the amount of time clinicians spent on wound assessments in a real-world environment using wound assessment digital application utilizing Artificial Intelligence (AI) vs. manual methods. The study also aimed at comparing the proportion of captured quality wound images on the first attempt by the assessment method. Methods Clinicians practicing at Valley Wound Center who agreed to join the study were asked to record the time needed to complete wound assessment activities for patients with active wounds referred for a routine evaluation on the follow-up days at the clinic. Assessment activities included: labelling wounds, capturing images, measuring wounds, calculating surface areas, and transferring data into the patient’s record. Results A total of 91 patients with 115 wounds were assessed. The average time to capture and access wound image with the AI digital tool was significantly faster than a standard digital camera with an average of 62 seconds (P<0.001). The digital application was significantly faster by 77% at accurately measuring and calculating the wound surface area with an average of 45.05 seconds (P<0.001). Overall, the average time to complete a wound assessment using Swift was significantly faster by 79%. Using the AI application, the staff completed all steps in about half of the time (54%) normally spent on manual wound evaluation activities. Moreover, acquiring acceptable wound image was significantly more likely to be achieved the first time using the digital tool than the manual methods (92.2% vs. 75.7%, P<0.004). Conclusions Using the digital assessment tool saved significant time for clinicians in assessing wounds. It also successfully captured quality wound images at the first attempt.
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Affiliation(s)
| | | | - Deborah Babb
- Valley Wound Healing Centre Inc, Modesto, California, United States of America
| | - Robert D. J. Fraser
- Swift Medical Inc., Toronto, ON, Canada
- Arthur Labatt Family School of Nursing, Western University, London, ON, Canada
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Stephenson AL, Sullivan EE, Hoffman AR. Primary care physician leaders’ perspectives on opportunities and challenges in healthcare leadership: a qualitative study. BMJ LEADER 2022; 7:28-32. [PMID: 37013883 DOI: 10.1136/leader-2022-000591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 05/11/2022] [Indexed: 11/04/2022]
Abstract
BackgroundThere is an increasing demand for physicians to assume leadership roles in hospitals, health systems, clinics and community settings, given the documented positive outcomes of physician leadership and the systemic shifts towards value-based care. The purpose of this study is to examine how primary care physicians (PCPs) perceive and experience leadership roles. Better understanding how PCPs perceive leadership affords the opportunity to influence changes in primary care training in order to more adequately prepare and support physicians for current and future leadership roles.MethodsThis study used qualitative interviews, conducted from January to May 2020. The participants included 27 PCPs, recruited via the Harvard Medical School Center for Primary Care newsletters and through snowball sampling techniques. Participants worked in 22 different organisations, including major urban health systems, corporate pharmacy, public health departments and academic medical centres.ResultsUsing content analysis and qualitative comparative analysis methodologies, three major themes and seven subthemes emerged from the interviews. The primary themes included the advantage PCPs have in leadership positions, the lack of leadership training and development, and disincentives to leading.ConclusionsWhile PCPs perceive primary care to hold a unique position that would incline them towards leadership, the lack of training and other noted disincentives are barriers to leadership. Therefore, health organisations should seek to invest in, better train and promote PCPs in leadership.
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Affiliation(s)
- Amber L Stephenson
- David D. Reh School of Business, Clarkson University, Schenectady, New York, USA
| | - Erin E Sullivan
- Sawyer School of Business, Suffolk University, Boston, Massachusetts, USA
- Center for Primary Care, Harvard Medical School, Boston, Massachusetts, USA
| | - Aaron R Hoffman
- Center for Primary Care, Harvard Medical School, Boston, Massachusetts, USA
- Atrius Health, Boston, Massachusetts, USA
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Improving Blood Product Transfusion Premedication Plan Documentation: A Single-institution Quality Improvement Effort. Pediatr Qual Saf 2022; 7:e572. [PMID: 35720859 PMCID: PMC9197348 DOI: 10.1097/pq9.0000000000000572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2021] [Accepted: 05/16/2022] [Indexed: 11/26/2022] Open
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Boone CE, Celhay P, Gertler P, Gracner T, Rodriguez J. How scheduling systems with automated appointment reminders improve health clinic efficiency. JOURNAL OF HEALTH ECONOMICS 2022; 82:102598. [PMID: 35172242 DOI: 10.1016/j.jhealeco.2022.102598] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 01/03/2022] [Accepted: 01/28/2022] [Indexed: 06/14/2023]
Abstract
Missed clinic appointments or no-shows burden health care systems through inefficient use of staff time and resources. Scheduling software with automatic appointment reminders shows promise to improve clinics' management through timely cancellations and re-scheduling, but at-scale evidence is missing. We study a nationwide text message appointment reminder program in Chile implemented at primary care clinics for patients with chronic disease. Using longitudinal clinic-level data, we find that the program did not change the number of visits by chronic patients eligible to receive the reminder but visits from other patients ineligible to receive reminders increased by 5.0% in the first year and 7.4% in the second. Clinics treating more chronic patients and those with a relatively younger patient population benefited more from the program. Scheduling systems with automatic appointment reminders were effective in increasing clinics' ability to care for more patients, likely due to timely cancellations and re-scheduling.
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Affiliation(s)
| | - Pablo Celhay
- Escuela de Gobierno and Instituto de Economia, Pontifica Universidad Catolica de Chile
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Murphy DR, Justice B, Bise CG, Timko M, Stevans JM, Schneider MJ. The primary spine practitioner as a new role in healthcare systems in North America. Chiropr Man Therap 2022; 30:6. [PMID: 35139859 PMCID: PMC8826679 DOI: 10.1186/s12998-022-00414-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 01/18/2022] [Indexed: 11/10/2022] Open
Abstract
Background In an article published in 2011, we discussed the need for a new role in health care systems, referred to as the Primary Spine Practitioner (PSP). The PSP model was proposed to help bring order to the chaotic nature of spine care. Over the past decade, several efforts have applied the concepts presented in that article. The purpose of the present article is to discuss the ongoing need for the PSP role in health care systems, present persistent barriers, report several examples of the model in action, and propose future strategies. Main body The management of spine related disorders, defined here as various disorders related to the spine that produce axial pain, radiculopathy and other related symptoms, has received significant international attention due to the high costs and relatively poor outcomes in spine care. The PSP model seeks to bring increased efficiency, effectiveness and value. The barriers to the implementation of this model have been significant, and responses to these barriers are discussed. Several examples of PSP integration are presented, including clinic systems in primary care and hospital environments, underserved areas around the world and a program designed to reduce surgical waiting lists. Future strategies are proposed for overcoming the continuing barriers to PSP implementation in health care systems more broadly. Conclusion Significant progress has been made toward integrating the PSP role into health care systems over the past 10 years. However, much work remains. This requires substantial effort on the part of those involved in the development and implementation of the PSP model, in addition to support from various stakeholders who will benefit from the proposed improvements in spine care.
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Affiliation(s)
- Donald R Murphy
- Department of Family Medicine, Alpert Medical School of Brown University, 133 Dellwood Road, Cranston, RI, 02920, USA
| | - Brian Justice
- Excellus BlueCross BlueShield, 165 Court Street, Rochester, NY, 14647, USA
| | - Christopher G Bise
- Department of Physical Therapy, University of Pittsburgh, Bridgeside Point 1, 100 Technology Drive, Suite 210, Pittsburgh, PA, 15219-3130, USA
| | - Michael Timko
- Department of Physical Therapy, University of Pittsburgh, Bridgeside Point Suite 228, 100 Technology Drive, Suite 210, Pittsburgh, PA, 15219-3130, USA
| | - Joel M Stevans
- Department of Physical Therapy, University of Pittsburgh, Bridgeside Point 1, 100 Technology Drive, Suite 500, Pittsburgh, PA, 15219-3130, USA
| | - Michael J Schneider
- Department of Physical Therapy, University of Pittsburgh, Bridgeside Point 1, 100 Technology Drive, Suite 500, Pittsburgh, PA, 15219-3130, USA.
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Swedlund M, Kamnetz S, Birstler J, Trowbridge E, Arndt B, Micek M, Lochner J, Pandhi N. Reduction in Medication Refill Encounters Through Primary Care Redesign Workflow Changes. J Ambul Care Manage 2022; 45:36-41. [PMID: 34690304 DOI: 10.1097/jac.0000000000000398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
With a goal of improving efficiency and reducing workload outside of visits, we sought to examine a primary care redesign process aimed at reducing refill requests made outside of office visits. Data on the number of refill encounters per panel member were collected at 17 clinics before, during, and after the implementation of a redesign process. There was an initial reduction in the number of medication refill encounters, and the rate of refill encounters continued to decline following implementation. Variation across clinic contexts suggests that redesign processes may need to be tailored for different settings to optimize effectiveness.
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Affiliation(s)
- Matthew Swedlund
- Department of Family Medicine and Community Health (Drs Swedlund, Kamnetz, Arndt, and Lochner), Division of General Internal Medicine, Department of Medicine (Drs Trowbridge and Micek), School of Medicine and Public Health, Department of Biostatistics and Medical Informatics (Ms Birstler), Department of Family and Community Medicine, University of New Mexico, Albuquerque (Dr Pandhi)
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Sinsky CA, Brown RL, Stillman MJ, Linzer M. COVID-Related Stress and Work Intentions in a Sample of US Health Care Workers. Mayo Clin Proc Innov Qual Outcomes 2021; 5:1165-1173. [PMID: 34901752 PMCID: PMC8651505 DOI: 10.1016/j.mayocpiqo.2021.08.007] [Citation(s) in RCA: 115] [Impact Index Per Article: 38.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/12/2023] Open
Abstract
OBJECTIVE To evaluate relationships between coronavirus disease 2019 (COVID-19)-related stress and work intentions in a sample of US health care workers. PATIENTS AND METHODS Between July 1 and December 31, 2020, health care workers were surveyed for fear of viral exposure or transmission, COVID-19-related anxiety or depression, work overload, burnout, and intentions to reduce hours or leave their jobs. RESULTS Among 20,665 respondents at 124 institutions (median organizational response rate, 34%), intention to reduce hours was highest among nurses (33.7%; n=776), physicians (31.4%; n=2914), and advanced practice providers (APPs; 28.9%; n=608) while lowest among clerical staff (13.6%; n=242) and administrators (6.8%; n=50; all P<.001). Burnout (odds ratio [OR], 2.15; 95% CI, 1.93 to 2.38), fear of exposure, COVID-19-related anxiety/depression, and workload were independently related to intent to reduce work hours within 12 months (all P<.01). Intention to leave one's practice within 2 years was highest among nurses (40.0%; n=921), APPs (33.0%; n=694), other clinical staff (29.4%; n=718), and physicians (23.8%; n=2204) while lowest among administrators (12.6%; n=93; all P<.001). Burnout (OR, 2.57; 95% CI, 2.29 to 2.88), fear of exposure, COVID-19-related anxiety/depression, and workload were predictors of intent to leave. Feeling valued by one's organization was protective of reducing hours (OR, 0.65; 95% CI, 0.59 to 0.72) and intending to leave (OR, 0.40; 95% CI, 0.36 to 0.45; all P<.01). CONCLUSION Approximately 1 in 3 physicians, APPs, and nurses surveyed intend to reduce work hours. One in 5 physicians and 2 in 5 nurses intend to leave their practice altogether. Reducing burnout and improving a sense of feeling valued may allow health care organizations to better maintain their workforces postpandemic.
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Affiliation(s)
| | | | - Martin J. Stillman
- Department of Medicine, Hennepin Health System and University of Minnesota, Minneapolis
| | - Mark Linzer
- Department of Medicine, Hennepin Health System and University of Minnesota, Minneapolis
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Abstract
BACKGROUND Clerical burdens have strained primary care providers already facing a shifting health care landscape and workforce shortages. These pressures may cause burnout and job dissatisfaction, with negative implications for patient care. Medical scribes, who perform real-time electronic health record documentation, have been posited as a solution to relieve clerical burdens, thus improving provider satisfaction and other outcomes. OBJECTIVE The purpose of this study is to identify and synthesize the published research on medical scribe utilization in primary care and safety net settings. RESEARCH DESIGN We conducted a review of the literature to identify outcomes studies published between 2010 and 2020 assessing medical scribe utilization in primary care settings. Searches were conducted in PubMed and supplemented by a review of the gray literature. Articles for inclusion were reviewed by the study authors and synthesized based on study characteristics, medical scribe tasks, and reported outcomes. RESULTS We identified 21 publications for inclusion, including 5 that examined scribes in health care safety net settings. Scribe utilization was consistently reported as being associated with improved productivity and efficiency, provider experience, and documentation quality. Findings for patient experience were mixed. CONCLUSIONS Published studies indicate scribe utilization in primary care may improve productivity, clinic and provider efficiencies, and provider experience without diminishing the patient experience. Further large-scale research is needed to validate the reliability of study findings and assess additional outcomes, including how scribes enhance providers' ability to advance health equity.
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Arabadjis SD, Sullivan EE. Data and HIT systems in primary care settings: an analysis of perceptions and use. J Health Organ Manag 2021; ahead-of-print. [PMID: 33354961 DOI: 10.1108/jhom-03-2020-0071] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
PURPOSE Electronic Health Records (EHRs) and other Health Information Technologies (HITs) pose significant challenges for clinicians, administrators and managers in the field of primary care. While there is an abundance of literature on the challenges of HIT systems in primary care, there are also practices where HITs are well-integrated and useful for care delivery. This study aims to (1) understand how exemplary primary care practices conceptualized data and HIT system use in their care delivery and (2) describe components that support and promote data and HIT system use in care delivery. DESIGN/METHODOLOGY/APPROACH This paper is a sub-analysis of a larger qualitative data set on exemplary primary care in which data was collected using in-depth interviews, observations, field notes and primary source documents from week-long site visits at each organization. Using a combination of qualitative analysis methods including elements of thematic analysis, discourse analysis, and qualitative comparison analysis, we examined HIT-related data across six exemplary primary care organizations. FINDINGS Three key components were identified that underlie engagement with data and HIT systems: data audience identification, defined data purpose and structures for participation in both data design and maintenance. ORIGINALITY/VALUE Within the context of primary care, these findings have implications for effective integration of HIT systems into primary care delivery.
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Affiliation(s)
- Sophia D Arabadjis
- Geography, University of California Santa Barbara, Santa Barbara, California, USA
| | - Erin E Sullivan
- Sawyer Business School, Suffolk University, Boston, Massachusetts, USA.,Center for Primary Care, Harvard Medical School, Boston, Massachusetts, USA
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16
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The impact of organizational culture on professional fulfillment and burnout in an academic department of medicine. PLoS One 2021; 16:e0252778. [PMID: 34106959 PMCID: PMC8189486 DOI: 10.1371/journal.pone.0252778] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 05/21/2021] [Indexed: 11/19/2022] Open
Abstract
Physician wellness is vital to career satisfaction, provision of high quality patient care, and the successful education of the next generation of physicians. Despite this, the number of physicians experience symptoms of burnout is rising. To assess the impact of organizational culture on physicians' professional fulfillment and burnout, we surveyed full-time Department of Medicine members at the University of Toronto. A cross-sectional survey assessed: physician factors (age, gender, minority status, disability, desire to reduce clinical workload); workplace culture (efforts to create a collegial environment, respectful/civil interactions, confidence to address unprofessionalism without reprisal, witnessed and/or personally experienced unprofessionalism); professional fulfillment and burnout using the Stanford Professional Fulfillment Index. We used multivariable linear regression to examine the relationship of measures of workplace culture on professional fulfillment and burnout (scores 0-10), controlling for physician factors. Of 419 respondents (52.0% response rate), we included 400 with complete professional fulfillment and burnout data in analyses (60% ≤ age 50, 45% female). Mean scores for professional fulfillment and burnout were 6.7±1.9 and 2.8±1.9, respectively. Controlling for physician factors, professional fulfillment was associated with satisfaction with efforts to create a collegial environment (adjusted beta 0.45, 95% CI 0.21 to 0.70) and agreement that colleagues were respectful/civil (adjusted beta 0.85, 95% CI 0.53 to 1.17). Lower professional fulfillment was associated with higher burnout scores. Controlling for professional fulfillment and physician factors, lower confidence in taking action to address unprofessionalism (adjusted beta -0.22, 95% CI -0.40 to -0.03) was associated with burnout. Organizational culture and physician factors had an impact on professional fulfillment and burnout. Professional fulfillment partially mediated the relationship between organizational culture and burnout. Strategies that promote inclusion, respect and civility, and safe ways to report workplace unprofessionalism are needed in academic medicine.
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17
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Tepe V, Knott A. The Technical Assistant Model: Efficiency in Maternal Fetal Medicine. JOURNAL OF DIAGNOSTIC MEDICAL SONOGRAPHY 2021. [DOI: 10.1177/87564793211018668] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective: To analyze how technical assistants benefit diagnostic medical sonography settings by improving efficiency and patient care. Materials & Methods: Credentialed obstetric sonographers who currently work in maternal fetal medicine were surveyed. Closed-ended and open-ended questions were used to examine effectiveness, usefulness, and overall satisfaction with the technical assistant position. In addition, quantitative methods were used to compare the time efficiency of technical assistants with medical assistants in obstetric settings. Results: The majority of sonographers and providers view technical assistants in a positive manner and indicated that the existence of the technical assistant role improved clinic flow. When compared with studies regarding medical assistant efficiency, this study showed shorter wait times for patients. Conclusion: The data supports that the presence of a technical assistant in clinic increases the overall efficiency of the clinic, which could allow providers to see more patients and reduce wait times for critical appointments. This could also lead to a more cost-effective system, especially when compared to alternative options such as hiring more providers or sonographers. These findings should encourage obstetric and gynecological sonography clinics to implement trained technical assistants to address clinic inefficiency, sonographer burnout, and sonographer and practitioner satisfaction.
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18
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Sharma HP. Enhancing practice efficiency: A key organizational strategy to improve professional fulfillment in allergy and immunology. Ann Allergy Asthma Immunol 2020; 126:235-239. [PMID: 33309885 DOI: 10.1016/j.anai.2020.12.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Revised: 11/11/2020] [Accepted: 12/02/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVE To review evidence-based strategies that have been noted to improve professional fulfillment and reduce burnout by enhancing practice efficiency. DATA SOURCES A comprehensive literature review was conducted to evaluate the strategies to improve efficiency of practice-a key driver of burnout among physicians. STUDY SELECTIONS Studies of efficiency-enhancing practices relevant to allergy-immunology were included. RESULTS Professional burnout is prevalent among physicians and is associated with negative outcomes affecting physicians, patients, and health care organizations. Recent surveys suggest at least 35% of US allergists-immunologists experience burnout. There are multiple drivers of professional burnout, some at the individual level and others at the organizational or practice level. Strategies to improve professional fulfillment may be conceptualized using the Stanford physician wellness framework, in which efforts target the following 3 reciprocal domains: culture, personal resilience, and practice efficiency. Organizational strategies that support physician well-being by creating a more efficient practice environment hold great promise, particularly for allergists-immunologists. The reduction of administrative burden and fostering of team-based care have been found in multiple studies to be cost-effective strategies to improve physician and patient satisfaction. CONCLUSION To ensure the well-being of the US allergy-immunology workforce and optimize patient outcomes, both private and academic allergy-immunology institutions should prioritize the adoption and iterative evaluation and refinement of these strategies to cocreate an efficient and ideal practice environment.
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Affiliation(s)
- Hemant P Sharma
- Division of Allergy and Immunology, Children's National Hospital, Washington, District of Columbia; George Washington University School of Medicine and Health Sciences, Washington, District of Columbia.
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19
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Chou SC, Venkatesh AK, Trueger NS, Pitts SR. Primary Care Office Visits For Acute Care Dropped Sharply In 2002-15, While ED Visits Increased Modestly. Health Aff (Millwood) 2020; 38:268-275. [PMID: 30715979 DOI: 10.1377/hlthaff.2018.05184] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The traditional model of primary care practices as the main provider of care for acute illnesses is rapidly changing. Over the past two decades the growth in emergency department (ED) visits has spurred efforts to reduce "inappropriate" ED use. We examined a nationally representative sample of office and ED visits in the period 2002-15. We found a 12 percent increase in ED use (from 385 to 430 visits per 1,000 population), which was dwarfed by a decrease of nearly one-third in the rate of acute care visits to primary care practices (from 938 to 637 visits per 1,000 population). The decrease in primary care acute visits was also present among two vulnerable populations: Medicaid beneficiaries and adults ages sixty-five and older, either in Medicare or privately insured. As acute care delivery shifts away from primary care practices, there is a growing need for integration and coordination across an increasingly diverse spectrum of venues where patients seek care for acute illnesses.
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Affiliation(s)
- Shih-Chuan Chou
- Shih-Chuan Chou ( ) is a fellow in health policy research and translation in the Department of Emergency Medicine, Brigham and Women's Hospital, in Boston, Massachusetts
| | - Arjun K Venkatesh
- Arjun K. Venkatesh is an assistant professor in the Department of Emergency Medicine, Yale School of Medicine, and a scientist in the Center for Outcome Research and Evaluation, Yale-New Haven Hospital, both in New Haven, Connecticut
| | - N Seth Trueger
- N. Seth Trueger is an assistant professor in the Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, in Chicago, Illinois
| | - Stephen R Pitts
- Stephen R. Pitts is an associate professor in the Department of Emergency Medicine, Emory University School of Medicine, and an associate professor in the Department of Epidemiology, Rollins School of Public Health, Emory University, both in Atlanta, Georgia
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20
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Piña IL, Di Palo KE, Brown MT, Choudhry NK, Cvengros J, Whalen D, Whitsel LP, Johnson J. Medication adherence: Importance, issues and policy: A policy statement from the American Heart Association. Prog Cardiovasc Dis 2020; 64:111-120. [PMID: 32800791 DOI: 10.1016/j.pcad.2020.08.003] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 08/05/2020] [Indexed: 02/06/2023]
Abstract
Medications do not work in patients who do not take them. This true statement highlights the importance of medication adherence. Providers are often frustrated by the lack of consistent medication adherence in the patients they care for. Today with the time constraints that providers face, it becomes difficult to discover the extent of non-adherence. There are certainly many challenges in medication adherence not only at the patient-provider level but also within a healthy system and finally in insurers and payment systems. In a cross-sectional survey of unintentional nonadherence in over 24,000 adults with chronic illness, including hypertension, diabetes and hyperlipidemia, 62% forgot to take medications and 37% had run out of their medications within a year. These sobering data necessitate immediate policy and systems solutions to support patients in adherence. Medication adherence for cardiovascular diseases (CVD) has the potential to change outcomes, such as blood pressure control and subsequent events. The American Heart Association (AHA)/American Stroke Association (ASA) has a goal of improving medication adherence in CVD and stroke prevention and treatment. This paper will explore medication adherence with all its inherent issues and suggest policy and structural changes that must happen in order to transform medication adherence levels in the U.S. and achieve the AHA/ASA's health impact goals.
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Affiliation(s)
- Ileana L Piña
- Wayne State University, Central Michigan University, Detroit, MI, United States of America.
| | | | - Marie T Brown
- Rush University Medical Center, Chicago, IL, United States of America
| | - Niteesh K Choudhry
- Brigham and Women's Hospital and Harvard Medical School, Boston, MA, United States of America
| | - Jamie Cvengros
- Rush University Medical Center, Chicago, IL, United States of America
| | - Deborah Whalen
- Boston University School of Medicine, Boston, MA, United States of America
| | - Laurie P Whitsel
- American Heart Association, Washington, DC, United States of America
| | - Janay Johnson
- American Heart Association, Washington, DC, United States of America
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21
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Moghaddamjou A, Wilson JRF, Martin AR, Gebhard H, Fehlings MG. Multidisciplinary approach to degenerative cervical myelopathy. Expert Rev Neurother 2020; 20:1037-1046. [PMID: 32683993 DOI: 10.1080/14737175.2020.1798231] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Degenerative cervical myelopathy (DCM) is a prevalent condition causing significant impairment spanning several domains of health. A multidisciplinary approach to the care of DCM would be ideal in utilizing complex treatments from different disciplines to address broad patient needs. AREAS COVERED In this article the authors will discuss the importance of multidisciplinary care and establish a general framework for its use. The authors will then highlight the potential role of a multidisciplinary team in each aspect of DCM care including assessment, diagnosis, decision-making, surgical intervention, non-operative therapy, monitoring, and postoperative care. EXPERT OPINION In order to provide comprehensive personalized care to DCM patients, it is necessary to have a multidisciplinary team composed by a combination of the patient, surgeon, primary care practitioner, neurologist, anesthesiologist, radiologist, physiatrist, nurses, physiotherapist, occupational therapist, pain specialist, and social workers all functioning independently and communicating to achieve a common goal.
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Affiliation(s)
- Ali Moghaddamjou
- Division of Neurosurgery and Spinal Program, Department of Surgery, University of Toronto , Toronto, Ontario, Canada
| | - Jamie R F Wilson
- Division of Neurosurgery and Spinal Program, Department of Surgery, University of Toronto , Toronto, Ontario, Canada.,Spinal Program, Toronto Western Hospital, University Health Network , Toronto, Ontario, Canada
| | - Allan R Martin
- Spinal Program, Toronto Western Hospital, University Health Network , Toronto, Ontario, Canada
| | - Harry Gebhard
- Department of Surgery, Canton Hospital Baden , Baden, Switzerland.,Department of Trauma, University Hospital Zurich, University of Zurich , Zurich, Switzerland
| | - Michael G Fehlings
- Division of Neurosurgery and Spinal Program, Department of Surgery, University of Toronto , Toronto, Ontario, Canada.,Spinal Program, Toronto Western Hospital, University Health Network , Toronto, Ontario, Canada
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22
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Schuttner L, Gunnink E, Sylling P, Taylor L, Fihn SD, Nelson K. Components of the Patient-Centered Medical Home Associated with Perceived Access to Primary Care. J Gen Intern Med 2020; 35:1736-1742. [PMID: 31993947 PMCID: PMC7280463 DOI: 10.1007/s11606-020-05668-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Revised: 11/27/2019] [Accepted: 01/12/2020] [Indexed: 10/25/2022]
Abstract
BACKGROUND Following implementation of the patient-centered medical home (PCMH) within the Department of Veterans Affairs (VA), access to primary care improved. However, understanding of how this occurred is lacking. OBJECTIVE To examine the association between organizational aspects of the PCMH model and access-related initiatives with patient perception of access to urgent, same-day, and routine care within the VA. DESIGN Cross-sectional PARTICIPANTS: Veterans who responded to the annual Survey of Healthcare Experiences of Patients in 2016 (N = 241,122 patients) and primary staff who responded to VA National Primary Care Provider and Staff Survey (N = 4815 staff). MAIN MEASURES Three outcomes of perception of access: percentage of patients responding in the highest category for same-day care (waiting ≤ 1 day), urgent care (always receiving care when needed), and routine care (always receiving checkups when desired). Predictors were staff-level report of access-related initiatives and organizational factors in the clinic. We used generalized estimating equations to model associations, adjusting for characteristics of patients and their respective clinics. KEY RESULTS Access was significantly better in clinics where staff reviewed performance reports (+ 0.9% in the highest perception of access for urgent care, P < 0.01; + 1.2% for routine care, P < 0.001), leadership was supportive of the PCMH (+ 1.6% for urgent care, P < 0.01), and initiatives to improve access included open access (+ 0.8% to + 1.7% across all outcomes, P < 0.01) and telehealth visits (+ 1.2% to + 1.4%, P < 0.001). Perceived access was worse in clinics with moderate staff burnout (- 1.1% to - 1.4%, P < 0.001), primary care provider turnover during the past year (- 1.0% to - 1.6%, P < 0.001), or medical support assistant turnover in the past year (- 0.9% to - 1.4%, P < 0.001). CONCLUSIONS Perception of access was strongly associated with identifiable organizational factors and access-related initiatives within VA primary care clinics that could be adopted by other health systems.
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Affiliation(s)
- Linnaea Schuttner
- VA Puget Sound Health Care System Health Services Research & Development, Seattle, WA, USA. .,Department of Medicine, University of Washington, Seattle, WA, USA.
| | - Eric Gunnink
- VA Puget Sound Health Care System Health Services Research & Development, Seattle, WA, USA
| | - Philip Sylling
- King County Department of Community and Human Services, Seattle, WA, USA
| | - Leslie Taylor
- VA Puget Sound Health Care System Health Services Research & Development, Seattle, WA, USA
| | - Stephan D Fihn
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - Karin Nelson
- VA Puget Sound Health Care System Health Services Research & Development, Seattle, WA, USA.,Department of Medicine, University of Washington, Seattle, WA, USA
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23
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Sørensen M, Groven KS, Gjelsvik B, Almendingen K, Garnweidner-Holme L. The roles of healthcare professionals in diabetes care: a qualitative study in Norwegian general practice. Scand J Prim Health Care 2020; 38:12-23. [PMID: 31960746 PMCID: PMC7054922 DOI: 10.1080/02813432.2020.1714145] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Objective: To explore the experiences of general practitioners (GPs), nurses and medical secretaries in providing multi-professional diabetes care and their perceptions of professional roles.Design, setting and subjects: Semi-structured interviews were conducted with six GPs, three nurses and two medical secretaries from five purposively sampled diabetes teams. Interviews were analysed thematically.Main outcome measures: Healthcare professionals' (HCPs') experiences of multi-professional diabetes care in general practice.Results: The involvement of nurses and medical secretaries (collaborating health care professionals) was mainly motivated by GPs' time pressure and their perception of diabetes care as easy to standardize. GPs reported that diabetes care had become more structured and continuous after the involvement of collaborating health care professionals (cHCPs). cHCPs defined their role differently from GPs, emphasizing that their approach included acknowledging patients' need for diabetes education, listening to their stories and meeting their need for emotional support. GPs appeared less involved in patients' emotional concerns and more focused on the biomedical aspects of illness. There was little emphasis on teamwork among GPs and cHCPs, and none of the practices used care plans to involve patients in decisions or unify treatment among professionals. Participants stated that institutional structures including a discriminatory remuneration system, lack of role descriptions and missing procedures for collaborative approaches were an obstacle to MPC.Conclusions: cHCPs worked independently under delegated leadership of the GPs. Although cHCPs had a complementary role, HCPs in general practice may not take full advantage of the potential of sharing patient responsibility and learning with, from and about each other. Contextual barriers for team-based care approaches should be addressed in future research.KEY POINTSIt has been suggested that multi-professional approaches improve quality of care in people with long-term conditions.In this study, nurses and medical secretaries perceived to have a complementary role to general practitioners (GPs) in diabetes care, focusing on patient education, building trusting relationships and providing patients with emotional support.As multi-professional collaboration was minimal, GPs, nurses and medical secretaries in the included practices may not take full advantage of the potential of sharing care responsibility and learning with, from and about each other.
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Affiliation(s)
- Monica Sørensen
- Faculty of Health Sciences, Department of Nursing and Health Promotion, OsloMet University, Oslo, Norway;
- CONTACT Monica Sørensen Faculty of Health Sciences, Department of Nursing and Health Promotion, OsloMet University, St. Olavs Plass, P.O. Box 4, 0130, Oslo, Norway
| | - Karen Synne Groven
- Faculty of Health Sciences, Department of Physiotherapy, OsloMet University, Oslo, Norway;
| | - Bjørn Gjelsvik
- Department of General Practice, Institute for Health and Society, University of Oslo, Oslo, Norway;
| | - Kari Almendingen
- Faculty of Health Sciences, Department of Nursing and Health Promotion, OsloMet University, Oslo, Norway
| | - Lisa Garnweidner-Holme
- Faculty of Health Sciences, Department of Nursing and Health Promotion, OsloMet University, Oslo, Norway
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24
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Sinnott C, Georgiadis A, Park J, Dixon-Woods M. Impacts of Operational Failures on Primary Care Physicians' Work: A Critical Interpretive Synthesis of the Literature. Ann Fam Med 2020; 18:159-168. [PMID: 32152021 PMCID: PMC7062478 DOI: 10.1370/afm.2485] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Revised: 07/11/2019] [Accepted: 07/22/2019] [Indexed: 11/09/2022] Open
Abstract
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.
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Affiliation(s)
- Carol Sinnott
- THIS Institute (The Healthcare Improvement Studies Institute), University of Cambridge, Cambridge, United Kingdom
| | - Alexandros Georgiadis
- THIS Institute (The Healthcare Improvement Studies Institute), University of Cambridge, Cambridge, United Kingdom
- ICON Plc, The Translation & Innovation Hub Building, Imperial College London, LondonUnited Kingdom
| | - John Park
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts
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25
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Zindel M, Cappelucci K, Knight HC, Busis N, Alexander C. Clinician Well-Being at Virginia Mason Kirkland Medical Center: A Case Study. NAM Perspect 2019; 2019:201908c. [PMID: 34532663 DOI: 10.31478/201908c] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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26
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Nelson SD, Rector HH, Brashear D, Mathe JL, Wen H, English SL, Hedges W, Lehmann CU, Ozdas-Weitkamp A, Stenner SP. Rebuilding the Standing Prescription Renewal Orders. Appl Clin Inform 2019; 10:77-86. [PMID: 30699459 DOI: 10.1055/s-0038-1675813] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
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.
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Affiliation(s)
- Scott D Nelson
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, United States.,HealthIT, Vanderbilt University Medical Center, Nashville, Tennessee, United States
| | - Hayley H Rector
- Pharmacy Department, Vanderbilt University Medical Center, Nashville, Tennessee, United States
| | - Daniel Brashear
- College of Pharmacy and Health Sciences, Lipscomb University, Nashville, Tennessee, United States
| | - Janos L Mathe
- HealthIT, Vanderbilt University Medical Center, Nashville, Tennessee, United States
| | - Haomin Wen
- HealthIT, Vanderbilt University Medical Center, Nashville, Tennessee, United States
| | - Stacey Lynn English
- College of Pharmacy and Health Sciences, Lipscomb University, Nashville, Tennessee, United States
| | - William Hedges
- College of Pharmacy and Health Sciences, Lipscomb University, Nashville, Tennessee, United States
| | - Christoph U Lehmann
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, United States.,HealthIT, Vanderbilt University Medical Center, Nashville, Tennessee, United States.,Department of Pediatrics, Vanderbilt University, Nashville, Tennessee, United States
| | - Asli Ozdas-Weitkamp
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, United States.,HealthIT, Vanderbilt University Medical Center, Nashville, Tennessee, United States
| | - Shane P Stenner
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, United States.,HealthIT, Vanderbilt University Medical Center, Nashville, Tennessee, United States
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27
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O'Malley AS, Rich EC, Shang L, Rose T, Ghosh A, Poznyak D, Peikes D. New approaches to measuring the comprehensiveness of primary care physicians. Health Serv Res 2019; 54:356-366. [PMID: 30613955 DOI: 10.1111/1475-6773.13101] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE To develop claims-based measures of comprehensiveness of primary care physicians (PCPs) and summarize their associations with health care utilization and cost. DATA SOURCES AND STUDY SETTING A total of 5359 PCPs caring for over 1 million Medicare fee-for-service beneficiaries from 1404 practices. STUDY DESIGN We developed Medicare claims-based measures of physician comprehensiveness (involvement in patient conditions and new problem management) and used a previously developed range of services measure. We analyzed the association of PCPs' comprehensiveness in 2013 with their beneficiaries' emergency department, hospitalizations rates, and ambulatory care-sensitive condition (ACSC) admissions (each per 1000 beneficiaries per year), and Medicare expenditures (per beneficiary per month) in 2014, adjusting for beneficiary, physician, practice, and market characteristics, and clustering. PRINCIPAL FINDINGS Each measure varied across PCPs and had low correlation with the other measures-as intended, they capture different aspects of comprehensiveness. For patients whose PCPs' comprehensiveness score was at the 75th vs 25th percentile (more vs less comprehensive), patients had lower service use (P < 0.05) in one or more measures: involvement with patient conditions: total Medicare expenditures, -$17.4 (-2.2 percent); hospitalizations, -5.5 (-1.9 percent); emergency department (ED) visits, -16.3 (-2.4 percent); new problem management: total Medicare expenditures, -$13.3 (-1.7 percent); hospitalizations, -7.0 (-2.4 percent); ED visits, -19.7 (-2.9 percent); range of services: ED visits, -17.1 (-2.5 percent). There were no significant associations between the comprehensiveness measures and ACSC admission rates. CONCLUSIONS These measures demonstrate strong content and predictive validity and reliability. Medicare beneficiaries of PCPs providing more comprehensive care had lower hospitalization rates, ED visits, and total Medicare expenditures.
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Affiliation(s)
- Ann S O'Malley
- Mathematica Policy Research, Washington, District of Columbia
| | - Eugene C Rich
- Mathematica Policy Research, Washington, District of Columbia
| | - Lisa Shang
- Mathematica Policy Research, Baltimore, Maryland
| | - Tyler Rose
- Mathematica Policy Research, Ann Arbor, Michigan
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28
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Meredith LS, Batorsky B, Cefalu M, Darling JE, Stockdale SE, Yano EM, Rubenstein LV. Long-term impact of evidence-based quality improvement for facilitating medical home implementation on primary care health professional morale. BMC FAMILY PRACTICE 2018; 19:149. [PMID: 30170541 PMCID: PMC6119243 DOI: 10.1186/s12875-018-0824-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Accepted: 07/18/2018] [Indexed: 11/10/2022]
Abstract
Background Poor morale among primary care providers (PCPs) and staff can undermine the success of patient-centered care models such as the patient-centered medical home that rely on highly coordinated inter-professional care teams. Medical home literature hypothesizes that participation in quality improvement can ease medical home transformation. No studies, however, have assessed the impact of quality improvement participation on morale (e.g., burnout or dissatisfaction) during transformation. The objective of this study is to examine whether primary care practices participating in evidence-based quality improvement (EBQI) during medical home transformation reduced burnout and increased satisfaction over time compared to non-participating practices. Methods We used a longitudinal quasi-experimental design to examine the impact of EBQI (vs. no EBQI), a multi-level, interdisciplinary approach for engaging frontline primary care practices in developing evidence-based improvement innovations and tools for spread on PCP and staff morale following the 2010 national implementation of the medical home model in the Veterans Health Administration. The sample included 356 primary care employees (107 primary care providers and 249 staff) from 23 primary care practices (6 intervention and 17 comparison) within one Veterans Health Administration region. Three intervention practices began EBQI in 2011 (early) and three more began EBQI in 2012 (late). Three waves of surveys were administered across 42 months beginning in November 2011 and ending in January 2016 approximately 2 years 18 months apart. We used repeated measures analysis of the survey data on medical home teams. Main outcome measures were the emotional exhaustion subscale from the Maslach Burnout Inventory, and job satisfaction. Results Six of 26 approved EBQI innovations directly addressed provider and staff morale; all 26 addressed medical home implementation challenges. Survey rates were 63% for baseline and 48% for both follow-up waves. Age was associated with lower burnout among PCPs (p = .039) and male PCPs had higher satisfaction (p = .037). Controlling for practice and PCP/staff characteristics, burnout increased by 5 points for PCPs in comparison practices (p = .024) and decreased by 1.4 points for early and 6.8 points (p = .039) for the late EBQI practices. Conclusions Engaging PCPs and staff in EBQI reduced burnout over time during medical home transformation. Electronic supplementary material The online version of this article (10.1186/s12875-018-0824-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Lisa S Meredith
- RAND Corporation, 1776 Main Street, Santa Monica, CA, 90407-2138, USA. .,VA HSR&D Center for the Study of Healthcare Innovation, Implementation, and Policy, Los Angeles, CA, USA.
| | | | - Matthew Cefalu
- RAND Corporation, 1776 Main Street, Santa Monica, CA, 90407-2138, USA
| | - Jill E Darling
- USC Center for Economic and Social Research, Los Angeles, CA, USA
| | - Susan E Stockdale
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation, and Policy, Los Angeles, CA, USA.,Department of Psychiatry and Biobehavioral Medicine, UCLA School of Medicine, Los Angeles, CA, USA
| | - Elizabeth M Yano
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation, and Policy, Los Angeles, CA, USA.,Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, CA, USA
| | - Lisa V Rubenstein
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation, and Policy, Los Angeles, CA, USA.,UCLA Schools of Medicine and Public Health, Los Angeles, CA, USA
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Gombolay M, Yang XJ, Hayes B, Seo N, Liu Z, Wadhwania S, Yu T, Shah N, Golen T, Shah J. Robotic assistance in the coordination of patient care. Int J Rob Res 2018. [DOI: 10.1177/0278364918778344] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
We conducted a study to investigate trust in and dependence upon robotic decision support among nurses and doctors on a labor and delivery floor. There is evidence that suggestions provided by embodied agents engender inappropriate degrees of trust and reliance among humans. This concern represents a critical barrier that must be addressed before fielding intelligent hospital service robots that take initiative to coordinate patient care. We conducted our experiment with nurses and physicians, and evaluated the subjects’ levels of trust in and dependence upon high- and low-quality recommendations issued by robotic versus computer-based decision support. The decision support, generated through action-driven learning from expert demonstration, produced high-quality recommendations that were accepted by nurses and physicians at a compliance rate of 90%. Rates of Type I and Type II errors were comparable between robotic and computer-based decision support. Furthermore, embodiment appeared to benefit performance, as indicated by a higher degree of appropriate dependence after the quality of recommendations changed over the course of the experiment. These results support the notion that a robotic assistant may be able to safely and effectively assist with patient care. Finally, we conducted a pilot demonstration in which a robot-assisted resource nurses on a labor and delivery floor at a tertiary care center.
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Affiliation(s)
| | - Xi Jessie Yang
- Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Bradley Hayes
- Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Nicole Seo
- Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Zixi Liu
- Massachusetts Institute of Technology, Cambridge, MA, USA
| | | | - Tania Yu
- Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Neel Shah
- Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Toni Golen
- Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Julie Shah
- Massachusetts Institute of Technology, Cambridge, MA, USA
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Li Z, Yang J, Wu Y, Pan Z, He X, Li B, Zhang L. Challenges for the surgical capacity building of township hospitals among the Central China: a retrospective study. Int J Equity Health 2018; 17:55. [PMID: 29720175 PMCID: PMC5932883 DOI: 10.1186/s12939-018-0766-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Accepted: 04/16/2018] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND China's rapid transition in healthcare service system has posed considerable challenges for the primary care system. Little is known regarding the capacity of township hospitals (THs) to deliver surgical care in rural China with over 600 million lives. We aimed to ascertain its current performance, barriers, and summary lessons for its re-building in central China. METHODS This study was conducted in four counties from two provinces in central China. The New Rural Cooperative Medical System (NRCMS) claim data from two counties in Hubei province was analyzed to describe the current situation of surgical care provision. Based on previous studies, self-administered questionnaire was established to collect key indicators from 60 THs from 2011 to 2015, and social and economic statuses of the sampling townships were collected from the local statistical yearbook. Semi-structured interviews were conducted among seven key administrators in the THs that did not provide appendectomy care in 2015. Determinants of appendectomy care provision were examined using a negative binominal regression model. RESULTS First, with the rapid increase in inpatient services provided by the THs, their proportion of surgical service provision has been nibbled by out-of-county facilities. Second, although DY achieved a stable performance, the total amount of appendectomy provided by the 60 THs decreased to 589 in 2015 from 1389 in 2011. Moreover, their proportion reduced to 26.77% in 2015 from 41.84% in 2012. Third, an increasing number of THs did not provide appendectomy in 2015, with the shortage of anesthesiologists and equipment as the most mentioned reasons (46.43%). Estimation results from the negative binomial model indicated that the annual average per capita disposable income and tightly integrated delivery networks (IDNs) negatively affected the amount of appendectomy provided by THs. By contrast, the probability of appendectomy provision by THs was increased by performance-related payment (PRP). Out-of-pocket (OOP) cost gap of appendectomy services between the two different levels of facilities, payment method, and the size of THs presented no observable improvement to the likelihood of appendectomy care in THs. CONCLUSION The county-level health system did not effectively respond to the continuously increasing surgical care need. The surgical capacity of THs declined with the surgical patterns' simplistic and quantity reduction. Deficits and critical challenges for surgical capacity building in central China were identified, including shortage of human resources and medical equipment and increasing income. Moreover, tight IDNs do not temporarily achieve capacity building. Therefore, the reimbursement rate should be further ranged, and physicians should be incentivized appropriately. The administrators, policy makers, and medical staff of THs should be aware of these findings owing to the potential benefits for the capacity building of the rural healthcare system.
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Affiliation(s)
- Zhong Li
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, No 13 Hangkong Road, Qiaokou District Wuhan, Hubei, 430030 China
| | - Jian Yang
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, No 13 Hangkong Road, Qiaokou District Wuhan, Hubei, 430030 China
- Department of Medical Affairs, Guangdong General Hospital, Guangzhou, 510080 Guangdong China
| | - Yue Wu
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, No 13 Hangkong Road, Qiaokou District Wuhan, Hubei, 430030 China
| | - Zijin Pan
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, No 13 Hangkong Road, Qiaokou District Wuhan, Hubei, 430030 China
| | - Xiaoqun He
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, No 13 Hangkong Road, Qiaokou District Wuhan, Hubei, 430030 China
| | - Boyang Li
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, No 13 Hangkong Road, Qiaokou District Wuhan, Hubei, 430030 China
| | - Liang Zhang
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, No 13 Hangkong Road, Qiaokou District Wuhan, Hubei, 430030 China
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Casalino LP. Technical Assistance for Primary Care Practice Transformation: Free Help to Perform Unpaid Labor? Ann Fam Med 2018; 16:S12-S15. [PMID: 29632220 PMCID: PMC5891308 DOI: 10.1370/afm.2226] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Accepted: 02/20/2018] [Indexed: 02/06/2023] Open
Affiliation(s)
- Lawrence P Casalino
- Department of Healthcare Policy and Research, Weill Cornell Medicine/New York-Presbyterian Hospital, New York, New York
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Anskär E, Lindberg M, Falk M, Andersson A. Time utilization and perceived psychosocial work environment among staff in Swedish primary care settings. BMC Health Serv Res 2018. [PMID: 29514637 PMCID: PMC5842529 DOI: 10.1186/s12913-018-2948-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Background Over the past decades, reorganizations and structural changes in Swedish primary care have affected time utilization among health care professionals. Consequently, increases in administrative tasks have substantially reduced the time available for face-to-face consultations. This study examined how work-time was utilized and the association between work time utilization and the perceived psychosocial work environment in Swedish primary care settings. Methods This descriptive, multicentre, cross-sectional study was performed in 2014–2015. Data collection began with questionnaire. In the first section, respondents were asked to estimate how their workload was distributed between patients (direct and indirect patient work) and other work tasks. The questionnaire also comprised the Copenhagen Psychosocial Questionnaire, which assessed the psychosocial work environment. Next a time study was conducted where the participants reported their work-time based on three main categories: direct patient-related work, indirect patient-related work, and other work tasks. Each main category had a number of subcategories. The participants recorded the time spent (minutes) on each work task per hour, every day, for two separate weeks. Eleven primary care centres located in southeast Sweden participated. All professionals were asked to participate (n = 441), including registered nurses, primary care physicians, care administrators, nurse assistants, and allied professionals. Response rates were 75% and 79% for the questionnaires and the time study, respectively. Results All health professionals allocated between 30.9% - 37.2% of their work-time to each main category: direct patient work, indirect patient work, and other work. All professionals estimated a higher proportion of time spent in direct patient work than they reported in the time study. Physicians scored highest on the psychosocial scales of quantitative demands, stress, and role conflicts. Among allied professionals, the proportion of work-time spent on administrative tasks was associated with more role conflicts. Younger staff perceived more adverse working conditions than older staff. Conclusions This study indicated that Swedish primary care staff spent a limited proportion of their work time directly with patients. PCPs seemed to perceive their work environment in negative terms to a greater extent than other staff members. This study showed that work task allocations influenced the perceived psychosocial work environment. Electronic supplementary material The online version of this article (10.1186/s12913-018-2948-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Eva Anskär
- Department of Medical and Health Sciences, Linköping University, Linköping, Sweden. .,Primary Health Care Centre in Mantorp, and Department of Medical and Health Sciences, Linköping University, Mantorp, Sweden. .,Research and Development Unit, and Department of Medical and Health Sciences, Linköping University, Linköping, Sweden.
| | - Malou Lindberg
- Department of Medical and Health Sciences, Linköping University, Linköping, Sweden.,1177 Medical Advisory Service, Linköping, Sweden
| | - Magnus Falk
- Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
| | - Agneta Andersson
- Department of Medical and Health Sciences, Linköping University, Linköping, Sweden.,Research and Development Unit, and Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
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Trockel M, Bohman B, Lesure E, Hamidi MS, Welle D, Roberts L, Shanafelt T. A Brief Instrument to Assess Both Burnout and Professional Fulfillment in Physicians: Reliability and Validity, Including Correlation with Self-Reported Medical Errors, in a Sample of Resident and Practicing Physicians. ACADEMIC PSYCHIATRY : THE JOURNAL OF THE AMERICAN ASSOCIATION OF DIRECTORS OF PSYCHIATRIC RESIDENCY TRAINING AND THE ASSOCIATION FOR ACADEMIC PSYCHIATRY 2018; 42:11-24. [PMID: 29196982 PMCID: PMC5794850 DOI: 10.1007/s40596-017-0849-3] [Citation(s) in RCA: 311] [Impact Index Per Article: 51.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/24/2017] [Accepted: 11/01/2017] [Indexed: 05/06/2023]
Abstract
OBJECTIVE The objective of this study was to evaluate the performance of the Professional Fulfillment Index (PFI), a 16-item instrument to assess physicians' professional fulfillment and burnout, designed for sensitivity to change attributable to interventions or other factors affecting physician well-being. METHODS A sample of 250 physicians completed the PFI, a measure of self-reported medical errors, and previously validated measures including the Maslach Burnout Inventory (MBI), a one-item burnout measure, the World Health Organization's abbreviated quality of life assessment (WHOQOL-BREF), and PROMIS short-form depression, anxiety, and sleep-related impairment scales. Between 2 and 3 weeks later, 227 (91%) repeated the PFI and the sleep-related impairment scale. RESULTS Principal components analysis justified PFI subscales for professional fulfillment, work exhaustion, and interpersonal disengagement. Test-retest reliability estimates were 0.82 for professional fulfillment (α = 0.91), 0.80 for work exhaustion (α = 0.86), 0.71 for interpersonal disengagement (α = 0.92), and 0.80 for overall burnout (α = 0.92). PFI burnout measures correlated highly (r ≥ 0.50) with their closest related MBI equivalents. Cohen's d effect size differences in self-reported medical errors for high versus low burnout classified using the PFI and the MBI were 0.55 and 0.44, respectively. PFI scales correlated in expected directions with sleep-related impairment, depression, anxiety, and WHOQOL-BREF scores. PFI scales demonstrated sufficient sensitivity to detect expected effects of a two-point (range 8-40) change in sleep-related impairment. CONCLUSIONS PFI scales have good performance characteristics including sensitivity to change and offer a novel contribution by assessing professional fulfillment in addition to burnout.
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Affiliation(s)
| | | | - Emi Lesure
- The Risk Authority Stanford, Palo Alto, CA, USA
| | | | - Dana Welle
- The Risk Authority Stanford, Palo Alto, CA, USA
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Leach B, Morgan P, Strand de Oliveira J, Hull S, Østbye T, Everett C. Primary care multidisciplinary teams in practice: a qualitative study. BMC FAMILY PRACTICE 2017; 18:115. [PMID: 29284409 PMCID: PMC5747144 DOI: 10.1186/s12875-017-0701-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Accepted: 12/13/2017] [Indexed: 12/30/2022]
Abstract
BACKGROUND Current recommendations for strengthening the US healthcare system consider restructuring primary care into multidisciplinary teams as vital to improving quality and efficiency. Yet, approaches to the selection of team designs remain unclear. This project describes current primary care team designs, primary care professionals' perceptions of ideal team designs, and perceived facilitating factors and barriers to implementing ideal team-based care. METHODS Qualitative study of 44 health care professionals at 6 primary care practices in North Carolina using focus group discussions and surveys. Data was analyzed using framework content analysis. RESULTS Practices used a variety of multidisciplinary team designs with the specific design being influenced by the social and policy context in which practices were embedded. Practices overwhelmingly located barriers to adopting ideal multidisciplinary teams as being outside of their individual practices and outside of their control. Participants viewed internal organizational contexts as the major facilitators of multidisciplinary primary care teams. The majority of practices described their ideal team design as including a social worker to meet the needs of socially complex patients. CONCLUSIONS Primary care multidisciplinary team designs vary across practices, shaped in part by contextual factors perceived as barriers outside of the practices' control. Facilitating factors within practices provide a culture of support to team members, but they are insufficient to overcome the perceived barriers. The common desire to add social workers to care teams reflects practices' struggles to meet the complex demands of patients and external agencies. Government or organizational policies should avoid one-size-fits-all approaches to multidisciplinary care teams, and instead allow primary care practices to adapt to their specific contextual circumstances.
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Affiliation(s)
- Brandi Leach
- Department of Community and Family Medicine, Duke University School of Medicine, Durham, NC USA
| | - Perri Morgan
- Department of Community and Family Medicine, Duke University School of Medicine, Durham, NC USA
| | | | - Sharon Hull
- Department of Community and Family Medicine, Duke University School of Medicine, Durham, NC USA
| | - Truls Østbye
- Department of Community and Family Medicine, Duke University School of Medicine, Durham, NC USA
| | - Christine Everett
- Department of Community and Family Medicine, Duke University School of Medicine, Durham, NC USA
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Glass DP, Kanter MH, Jacobsen SJ, Minardi PM. The impact of improving access to primary care. J Eval Clin Pract 2017; 23:1451-1458. [PMID: 28984018 PMCID: PMC5765488 DOI: 10.1111/jep.12821] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2017] [Revised: 08/03/2017] [Accepted: 08/04/2017] [Indexed: 11/29/2022]
Abstract
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.
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Affiliation(s)
- David P Glass
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Michael H Kanter
- The Permanente Federation and Associate Dean of the Medical School, Pasadena, CA, USA
| | - Steven J Jacobsen
- Department of Research & Evaluation, Kaiser Permanente Southern California, CA, USA
| | - Paul M Minardi
- Southern California Permanente Medical Group, Pasadena, CA, USA
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Changes in the Health Professions. J Ambul Care Manage 2017; 40:199-203. [DOI: 10.1097/jac.0000000000000203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Pharmacists' perspectives of the current status of pediatric asthma management in the U.S. community pharmacy setting. Int J Clin Pharm 2017; 39:935-944. [PMID: 28497209 DOI: 10.1007/s11096-017-0471-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2016] [Accepted: 04/18/2017] [Indexed: 10/19/2022]
Abstract
Objective To explore community pharmacists' continuing education, counseling and communication practices, attitudes and barriers in relation to pediatric asthma management. Setting Community pharmacies in Michigan, United States. Methods Between July and September 2015 a convenience sample of community pharmacists was recruited from southeastern Michigan and asked to complete a structured, self-reported questionnaire. The questionnaire elucidated information on 4 general domains relating to pharmacists' pediatric asthma management including: (1) guidelines and continuing education (CE); (2) counseling and medicines; (3) communication and self-management practices; (4) attitudes and barriers to practice. Regression analyses were conducted to determine predictors towards pharmacists' confidence/frequency of use of communication/counseling strategies. Main outcome measure Confidence in counseling skills around asthma. Results 105 pharmacists completed the study questionnaire. Fifty-four percent of pharmacists reported participating in asthma related CE in the past year. Over 70% of pharmacists reported confidence in general communication skills, while a lower portion reported confidence in engaging in higher order self-management activities that involved tailoring the regimen (58%), decision-making (50%) and setting short-term (47%) and long-term goals (47%) with the patient and caregiver for managing asthma at home. Pharmacists who reported greater use of recommended communication/self-management strategies were more likely to report confidence in implementing these communication/self-management strategies when counseling caregivers and children with asthma [Beta (B) Estimate 0.58 SE (0.08), p < 0.001]. Female pharmacists [B Estimate -2.23 SE (1.01), p < 0.05] and those who reported beliefs around doctors being the sole provider of asthma education [B Estimate -1.00 SE (0.32), p < 0.01] were less likely to report confidence in implementing communication/self-management strategies. Conclusion A pharmacists' confidence may influence their ability to implement recommended self-management counseling strategies. This study showed that community pharmacists are confident in general communication. However pharmacists are reporting lower confidence levels in counseling on higher order self-management strategies with patients. More appropriate and targeted continuing education programs for pharmacists around asthma self-management education are recommended.
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Patel MR, Vichich J, Lang I, Lin J, Zheng K. Developing an evidence base of best practices for integrating computerized systems into the exam room: a systematic review. J Am Med Inform Assoc 2017; 24:e207-e215. [PMID: 27539198 PMCID: PMC7651892 DOI: 10.1093/jamia/ocw121] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Revised: 07/13/2016] [Accepted: 07/19/2016] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVE The introduction of health information technology systems, electronic health records in particular, is changing the nature of how clinicians interact with patients. Lack of knowledge remains on how best to integrate such systems in the exam room. The purpose of this systematic review was to (1) distill "best" behavioral and communication practices recommended in the literature for clinicians when interacting with patients in the presence of computerized systems during a clinical encounter, (2) weigh the evidence of each recommendation, and (3) rank evidence-based recommendations for electronic health record communication training initiatives for clinicians. METHODS We conducted a literature search of 6 databases, resulting in 52 articles included in the analysis. We extracted information such as study setting, research design, sample, findings, and implications. Recommendations were distilled based on consistent support for behavioral and communication practices across studies. RESULTS Eight behavioral and communication practices received strong support of evidence in the literature and included specific aspects of using computerized systems to facilitate conversation and transparency in the exam room, such as spatial (re)organization of the exam room, maintaining nonverbal communication, and specific techniques that integrate the computerized system into the visit and engage the patient. Four practices, although patient-centered, have received insufficient evidence to date. DISCUSSION AND CONCLUSION We developed an evidence base of best practices for clinicians to maintain patient-centered communications in the presence of computerized systems in the exam room. Further work includes development and empirical evaluation of evidence-based guidelines to better integrate computerized systems into clinical care.
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Affiliation(s)
- Minal R Patel
- Department of Health Behavior and Health Education, University of Michigan School of Public Health, Ann Arbor, MI
| | - Jennifer Vichich
- Department of Health Behavior and Health Education, University of Michigan School of Public Health, Ann Arbor, MI
| | - Ian Lang
- Department of Health Behavior and Health Education, University of Michigan School of Public Health, Ann Arbor, MI
| | - Jessica Lin
- Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor, MI
| | - Kai Zheng
- Department of Informatics, Donald Bren School of Information and Computer Sciences, University of California Irvine, Irvine, CA, USA
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Scheitel MR, Kessler ME, Shellum JL, Peters SG, Milliner DS, Liu H, Komandur Elayavilli R, Poterack KA, Miksch TA, Boysen J, Hankey RA, Chaudhry R. Effect of a Novel Clinical Decision Support Tool on the Efficiency and Accuracy of Treatment Recommendations for Cholesterol Management. Appl Clin Inform 2017; 8:124-136. [PMID: 28174820 PMCID: PMC5373758 DOI: 10.4338/aci-2016-07-ra-0114] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Accepted: 12/02/2016] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND The 2013 American College of Cardiology / American Heart Association Guidelines for the Treatment of Blood Cholesterol emphasize treatment based on cardiovascular risk. But finding time in a primary care visit to manually calculate cardiovascular risk and prescribe treatment based on risk is challenging. We developed an informatics-based clinical decision support tool, MayoExpertAdvisor, to deliver automated cardiovascular risk scores and guideline-based treatment recommendations based on patient-specific data in the electronic heath record. OBJECTIVE To assess the impact of our clinical decision support tool on the efficiency and accuracy of clinician calculation of cardiovascular risk and its effect on the delivery of guideline-consistent treatment recommendations. METHODS Clinicians were asked to review the EHR records of selected patients. We evaluated the amount of time and the number of clicks and keystrokes needed to calculate cardiovascular risk and provide a treatment recommendation with and without our clinical decision support tool. We also compared the treatment recommendation arrived at by clinicians with and without the use of our tool to those recommended by the guidelines. RESULTS Clinicians saved 3 minutes and 38 seconds in completing both tasks with MayoExpertAdvisor, used 94 fewer clicks and 23 fewer key strokes, and improved accuracy from the baseline of 60.61% to 100% for both the risk score calculation and guideline-consistent treatment recommendation. CONCLUSION Informatics solution can greatly improve the efficiency and accuracy of individualized treatment recommendations and have the potential to increase guideline compliance.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | - Rajeev Chaudhry
- Rajeev Chaudhry, MBBS,MPH, Associate Professor of Medicine, Division of Primary Care Internal Medicine, Knowledge and Delivery Center, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, TEL: (507) 255-3956, E-mail:
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Shanafelt TD, Noseworthy JH. Executive Leadership and Physician Well-being: Nine Organizational Strategies to Promote Engagement and Reduce Burnout. Mayo Clin Proc 2017; 92:129-146. [PMID: 27871627 DOI: 10.1016/j.mayocp.2016.10.004] [Citation(s) in RCA: 938] [Impact Index Per Article: 134.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2016] [Revised: 10/05/2016] [Accepted: 10/10/2016] [Indexed: 12/20/2022]
Abstract
These are challenging times for health care executives. The health care field is experiencing unprecedented changes that threaten the survival of many health care organizations. To successfully navigate these challenges, health care executives need committed and productive physicians working in collaboration with organization leaders. Unfortunately, national studies suggest that at least 50% of US physicians are experiencing professional burnout, indicating that most executives face this challenge with a disillusioned physician workforce. Burnout is a syndrome characterized by exhaustion, cynicism, and reduced effectiveness. Physician burnout has been shown to influence quality of care, patient safety, physician turnover, and patient satisfaction. Although burnout is a system issue, most institutions operate under the erroneous framework that burnout and professional satisfaction are solely the responsibility of the individual physician. Engagement is the positive antithesis of burnout and is characterized by vigor, dedication, and absorption in work. There is a strong business case for organizations to invest in efforts to reduce physician burnout and promote engagement. Herein, we summarize 9 organizational strategies to promote physician engagement and describe how we have operationalized some of these approaches at Mayo Clinic. Our experience demonstrates that deliberate, sustained, and comprehensive efforts by the organization to reduce burnout and promote engagement can make a difference. Many effective interventions are relatively inexpensive, and small investments can have a large impact. Leadership and sustained attention from the highest level of the organization are the keys to making progress.
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Affiliation(s)
- Tait D Shanafelt
- Director of the Program on Physician Well-being, Mayo Clinic, Rochester, MN.
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Lee K, Wright SM, Wolfe L. The clinically excellent primary care physician: examples from the published literature. BMC FAMILY PRACTICE 2016; 17:169. [PMID: 27964709 PMCID: PMC5153856 DOI: 10.1186/s12875-016-0569-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/30/2016] [Accepted: 11/30/2016] [Indexed: 11/10/2022]
Abstract
Clinical excellence is the ultimate goal in patient care. Exactly what the clinically excellent primary care physician (PCP) looks like and her characteristics have not been explicitly described. This manuscript serves to illustrate clinical excellence in primary care, using primarily case reports exemplifying physicians delivering holistic and patient-centred care to their patients. With an ever increasing demand for accessible and accountable health care, an understanding of the qualities desirable in primary care providers is now especially relevant.A literature review was conducted to identify compelling stories showing how excellent PCPs care for their patients. In the 2397 published works reviewed, we were able to find case reports and studies that exemplified every domain of the description of clinical excellence proposed and published by the Miller Coulson Academy of Clinical Excellence (MCACE). After reviewing these reports, the authors felt that the domains of excellence, as described by the MCACE, are practically applicable and relevant for primary care physicians. It is our hope that this paper prompts readers to reflect on clinical excellence in primary care.
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Affiliation(s)
- Kimberley Lee
- Division of General Internal Medicine, Johns Hopkins Bayview Medical Center, Johns Hopkins University School of Medicine, 5200 Eastern Ave., Mason F. Lord Center Tower, 2nd Floor, Baltimore, 21224, MD, USA
| | - Scott M Wright
- Division of General Internal Medicine, Johns Hopkins Bayview Medical Center, Johns Hopkins University School of Medicine, 5200 Eastern Ave., Mason F. Lord Center Tower, 2nd Floor, Baltimore, 21224, MD, USA.
| | - Leah Wolfe
- Division of General Internal Medicine, Johns Hopkins Bayview Medical Center, Johns Hopkins University School of Medicine, 5200 Eastern Ave., Mason F. Lord Center Tower, 2nd Floor, Baltimore, 21224, MD, USA
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Wong ES, Rosland AM, Fihn SD, Nelson KM. Patient-Centered Medical Home Implementation in the Veterans Health Administration and Primary Care Use: Differences by Patient Comorbidity Burden. J Gen Intern Med 2016; 31:1467-1474. [PMID: 27503440 PMCID: PMC5130955 DOI: 10.1007/s11606-016-3833-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2016] [Revised: 05/27/2016] [Accepted: 07/22/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND The patient-centered medical home (PCMH) model has several components to improve care for patients with high comorbidity, including greater access to face-to-face primary care. OBJECTIVE We examined whether high-comorbidity patients had larger increases in primary care provider (PCP) visits attributable to PCMH implementation in a large integrated health system relative to other patients enrolled in primary care. DESIGN, SUBJECTS AND MAIN MEASURES This longitudinal study examined a 1 % random sample of 9.3 million patients enrolled in the Veterans Health Administration (VHA) at any time between 2003 and 2013. Face-to-face visits with PCPs per quarter were identified through VHA administrative data. Comorbidity was measured using the Gagne index and patients with a weighted score of ≥ 2 were defined as high comorbidity. We applied interrupted time-series models to estimate marginal changes in PCP visits attributable to PCMH implementation. Differences in marginal changes were calculated across comorbidity groups (high vs. low). Analyses were stratified by age group to account for Medicare eligibility. KEY RESULTS Among age 65+ patients, PCMH was associated with greater PCP visits starting four and ten quarters following implementation for high- and low-comorbidity patients, respectively. Changes were larger for high-comorbidity patients (eight to 11 greater visits per 1000 patients per quarter). Among patients age < 65, PCMH was associated with greater visits for high-comorbidity patients starting eight quarters following implementation, but fewer visits for low-comorbidity patients in all quarters. The difference in visit changes across groups ranged from 18 to 67 visits per 1000 patients per quarter. CONCLUSIONS Increases in PCP visits attributable to PCMH were greater among patients with higher comorbidity. Health systems implementing PCMH should account for population-level comorbidity burden when planning for PCMH-related changes in PCP utilization.
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Affiliation(s)
- Edwin S Wong
- VA Puget Sound Health Care System, Center for Veteran-Centered and Value-Driven Care, 1660 S. Columbian Way, MS S-152, Seattle, WA, 98108, USA. .,Department of Health Services, University of Washington, Seattle, WA, USA.
| | - Ann-Marie Rosland
- Center for Clinical Management Research, VHA Ann Arbor Healthcare System, Ann Arbor, MI, USA.,Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Stephan D Fihn
- Office of Analytics and Business Intelligence, Veterans Health Administration, Seattle, WA, USA
| | - Karin M Nelson
- VA Puget Sound Health Care System, Center for Veteran-Centered and Value-Driven Care, 1660 S. Columbian Way, MS S-152, Seattle, WA, 98108, USA.,Department of Health Services, University of Washington, Seattle, WA, USA.,Department of Medicine, University of Washington, Seattle, WA, USA
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Falit BP, Pan HY, Smith BD, Alexander BM, Zietman AL. The Radiation Oncology Job Market: The Economics and Policy of Workforce Regulation. Int J Radiat Oncol Biol Phys 2016; 96:501-10. [DOI: 10.1016/j.ijrobp.2016.05.029] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Revised: 05/10/2016] [Accepted: 05/25/2016] [Indexed: 11/29/2022]
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Chang CH, O'Malley AJ, Goodman DC. Association between Temporal Changes in Primary Care Workforce and Patient Outcomes. Health Serv Res 2016; 52:634-655. [PMID: 27256769 DOI: 10.1111/1475-6773.12513] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To examine the association between 10-year temporal changes in the primary care workforce and Medicare beneficiaries' outcomes. DATA SOURCES 2001 and 2011 American Medical Association Masterfiles and fee-for-service Medicare claims. STUDY DESIGN/METHODS We calculated two primary care workforce measures within Primary Care Service Areas: the number of primary care physicians per 10,000 population (per capita) and the number of Medicare primary care full-time equivalents (FTEs) per 10,000 Medicare beneficiaries. The three outcomes were mortality, ambulatory care-sensitive condition (ACSC) hospitalizations, and emergency department (ED) visits. We measured the marginal association between changes in primary care workforce and patient outcomes using Poisson regression models. PRINCIPAL FINDINGS An increase of one primary care physician per 10,000 population was associated with 15.1 fewer deaths per 100,000 and 39.7 fewer ACSC hospitalizations per 100,000 (both p < .05). An increase of one Medicare primary care FTE per 10,000 beneficiaries was associated with 82.8 fewer deaths per 100,000, 160.8 fewer ACSC hospitalizations per 100,000, and 712.3 fewer ED visits per 100,000 (all p < .05). CONCLUSIONS Medicare beneficiaries' outcomes improved as the number of primary care physicians and their clinical effort increased.
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Affiliation(s)
- Chiang-Hua Chang
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH
| | - A James O'Malley
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH
| | - David C Goodman
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH.,Department of Pediatrics, Geisel School ofMedicine at Dartmouth, Hanover, NH
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Parente ST, Feldman R, Spetz J, Dowd B, Baggett EE. Wage Growth for the Health Care Workforce: Projecting the Affordable Care Act Impact. Health Serv Res 2016; 52:741-762. [PMID: 27140174 DOI: 10.1111/1475-6773.12497] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVE To predict changes in wage growth for health care workers based on projections of insurance enrollment from the Affordable Care Act (ACA). DATA SOURCES Enrollment data came from three large employers and a sampling of premiums from ehealthinsurance.com. Information on state Medicaid eligibility rules and costs were from the Kaiser Family Foundation. National predictions were based on the MEPS and Medicare Current Beneficiary surveys. Bureau of Labor Statistics data were used to estimate employment. STUDY DESIGN We projected health insurance enrollment by plan type using a health plan choice model. Using claims data, we measured the services demanded for each plan choice and year. Projections of labor demand were based on current output/input ratios. Changes in wages resulting from changes in labor demand from 2014 to 2021 were based on labor supply and demand elasticities. PRINCIPAL FINDINGS Expenditures required to retain and grow the health care workforce will increase substantially. Wages will increase most for professions with the greatest training requirements (physicians and registered nurses). The largest impact will be felt in 2015. CONCLUSIONS Projected wage increases for health care workers may drive substantial growth in insurance premiums and reduce the affordability of health insurance.
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Affiliation(s)
- Stephen T Parente
- Department of Finance, Carlson School of Management, University of Minnesota, Minneapolis, MN
| | - Roger Feldman
- Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis, MN
| | - Joanne Spetz
- Philip R. Lee Institute for Health Policy Studies, Center for the Health Professions, University of California, San Francisco, CA
| | - Bryan Dowd
- Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis, MN
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Gray CP, Harrison MI, Hung D. Medical Assistants as Flow Managers in Primary Care: Challenges and Recommendations. J Healthc Manag 2016. [DOI: 10.1097/00115514-201605000-00005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Rosenkrantz AB, Hughes DR, Duszak R. The U.S. Radiologist Workforce: An Analysis of Temporal and Geographic Variation by Using Large National Datasets. Radiology 2016; 279:175-84. [DOI: 10.1148/radiol.2015150921] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Abstract
BACKGROUND Recent efforts to revitalize primary care have centered on the patient-centered medical home (PCMH). Although enhanced access is an integral component of the PCMH model, the effect of PCMHs on access to primary care services is understudied. OBJECTIVE To determine whether PCMH practices are associated with better access to new appointments for nonelderly adults by direct measurement. RESEARCH DESIGN We estimated the relationship between practice PCMH status and access to care in multivariate regression models, adjusting for a robust set of patient, practice, and geographic characteristics; using data on 11,347 simulated patient calls to 7266 primary care practices across 10 US states merged with data on PCMH practices. PARTICIPANTS Trained field staff posing as patients (age younger than 65 y) seeking a new primary care appointment with varying insurance status (private, Medicaid, or self-pay). MEASURES Our primary predictor was practice PCMH status and our primary outcome was the ability of simulated patients to schedule a new appointment. Secondary outcomes included the number of days to that appointment; availability of after-hour appointments; and an appointment with an ongoing primary care provider. RESULTS Of the 7266 practices contacted for an appointment, 397 (5.5%) were National Committee for Quality Assurance-recognized PCMHs. In adjusted analyses, callers to PCMH practices compared with non-PCMH practices were more likely to schedule a new appointment (adjusted odds ratio=1.26 (95% CI, 1.01-1.58); P=0.04] and be offered after-hour appointments [adjusted odds ratio=1.36 (95% CI, 1.04-1.75); P=0.02]. DISCUSSION PCMH practices maybe associated with better access to new primary care appointments for nonelderly adults, those most likely to gain insurance under the Affordable Care Act.
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Casalino LP, Chen MA, Staub CT, Press MJ, Mendelsohn JL, Lynch JT, Miranda Y. Large Independent Primary Care Medical Groups. Ann Fam Med 2016; 14:16-25. [PMID: 26755779 PMCID: PMC4709151 DOI: 10.1370/afm.1890] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Revised: 10/19/2015] [Accepted: 11/08/2015] [Indexed: 11/09/2022] Open
Abstract
PURPOSE In the turbulent US health care environment, many primary care physicians seek hospital employment. Large physician-owned primary care groups are an alternative, but few physicians or policy makers realize that such groups exist. We wanted to describe these groups, their advantages, and their challenges. METHODS We identified 21 groups and studied 5 that varied in size and location. We conducted interviews with group leaders, surveyed randomly selected group physicians, and interviewed external observers-leaders of a health plan, hospital, and specialty medical group that shared patients with the group. We triangulated responses from group leaders, group physicians, and external observers to identify key themes. RESULTS The groups' physicians work in small practices, with the group providing economies of scale necessary to develop laboratory and imaging services, health information technology, and quality improvement infrastructure. The groups differ in their size and the extent to which they engage in value-based contracting, though all are moving to increase the amount of financial risk they take for their quality and cost performance. Unlike hospital-employed and multispecialty groups, independent primary care groups can aim to reduce health care costs without conflicting incentives to fill hospital beds and keep specialist incomes high. Each group was positively regarded by external observers. The groups are under pressure, however, to sell to organizations that can provide capital for additional infrastructure to engage in value-based contracting, as well as provide substantial income to physicians from the sale. CONCLUSIONS Large, independent primary care groups have the potential to make primary care attractive to physicians and to improve patient care by combining human scale advantages of physician autonomy and the small practice setting with resources that are important to succeed in value-based contracting.
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Affiliation(s)
- Lawrence P Casalino
- Department of Healthcare Policy and Research, Weill Cornell Medical College, New York, New York
| | - Melinda A Chen
- Department of Healthcare Policy and Research, Weill Cornell Medical College, New York, New York
| | | | - Matthew J Press
- Department of Healthcare Policy and Research, Weill Cornell Medical College, New York, New York
| | - Jayme L Mendelsohn
- Department of Healthcare Policy and Research, Weill Cornell Medical College, New York, New York
| | | | - Yesenia Miranda
- Department of Healthcare Policy and Research, Weill Cornell Medical College, New York, New York
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National projections of time, cost and failure in implantable device identification: Consideration of unique device identification use. Healthcare (Basel) 2015; 3:196-201. [DOI: 10.1016/j.hjdsi.2015.04.003] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2014] [Revised: 01/22/2015] [Accepted: 04/08/2015] [Indexed: 11/18/2022] Open
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