Visits to retail clinics grew fourfold from 2007 to 2009, although their share of overall outpatient visits remains low

Retail clinics have rapidly become a fixture of the US health care delivery landscape. We studied visits to retail clinics and found that they increased fourfold from 2007 to 2009, with an estimated 5.97?million retail clinic visits in 2009 alone. Compared with retail clinic patients in 2000-06, patients in 2007-09 were more likely to be age sixty-five or older (14.7?percent versus 7.5?percent). Preventive care-in particular, the influenza vaccine-was a larger component of care for patients at retail clinics in 2007-09, compared to patients in 2000-06 (47.5?percent versus 21.8?percent). Across all retail clinic visits, 44.4?percent in 2007-09 were on the weekend or during weekday hours when physician offices are typically closed. The rapid growth of retail clinics makes it clear that they are meeting a patient need. Convenience and after-hours accessibility are possible drivers of this growth. However, retail clinics make up a small share of overall visits in the outpatient setting, which include 117?million visits to emergency departments and 577?million visits to physician offices annually.     

When do older patients change primary care physicians?

BACKGROUND: Concerns have been raised about changes in the health care system that may disrupt continuity of care and thereby reduce the quality of that care. The purpose of this study was to look at the reasons that older patients give for changing primary care physicians (PCPs) and to look at relationships between the duration of the PCP-patient relationship and the perceived quality of primary care received. METHODS: We analyzed data collected during the first 2 years of a longitudinal study of primary care patients 65 years of age and older. Variables included sociodemographic characteristics, duration of relationship with current PCP, reasons for leaving last PCP, estimated numbers of visits to PCP, other clinics, and emergency departments, and admissions to hospitals and nursing homes in the last year, self-rated health, 2 measures of health-related quality of life, and the Components of Primary Care Index (CPCI). RESULTS: 799 patients of 23 PCPs were enrolled in year 1 of the longitudinal study, and 579 were re-evaluated in year 2. The mean and median PCP-patient relationship durations were 10.27 and 8 years, respectively. Duration of the PCP-patient relationship was associated with greater patient age, income, level of education, and frequency of visits to the PCP. Longer relationship duration was also associated with higher scores on all 8 CPCI subscales. The distribution of reasons for changing PCP was associated with duration of relationship; those with a longer relationship were more likely to change involuntarily. Insurance-related reasons for changing PCP were more common in those who had changed more recently. One hundred and fourteen (14%) changed PCP during the first year of the study. Three CPCI subscale scores predicted PCP change, accumulated knowledge, communication, and family orientation. Eighty-seven percent changed involuntarily, 44% for insurance-related reasons and 40% because their doctors had moved, retired, or died. CONCLUSIONS: Older patients, particularly those who are older and have more education and income, tend to stay with their PCPs until they are forced to change. The longer they stay in the relationship, the better they feel about the quality of the primary services they receive. Changes in the health care system may have increased the number of patients forced to change PCP.     

Pharmaceutical Role Expansion and Developments in Pharmacist-Physician Communication

Expanded clinical pharmacist professional roles in the team-based patient-centered medical home (PCMH) primary care environment require cooperative and collaborative relationships among pharmacists and primary care physicians (PCPs), but many PCPs have not previously worked in such a direct fashion with pharmacists. Additional roles, including formulary control, add further elements of complexity to the clinical pharmacist–PCP relationship that are not well described. Our objective was to characterize the nature of clinical pharmacist–PCP interprofessional collaboration across seven federally funded hospitals and associated primary care clinics, following pharmacist placement in primary care clinics and incorporation of expanded pharmacist roles. In-depth and semistructured interviews were conducted with 25 practicing clinical pharmacists and 17 PCPs. Qualitative thematic analysis revealed three major themes: (1) the complexities of electronic communication (particularly electronic nonformulary requests) as contributing to interprofessional tensions or misunderstandings for both groups, (2) the navigation of new roles and traditional hierarchy, with pharmacists using indirect communication to prevent PCP defensiveness to recommendations, and (3) a preference for onsite colocation for enhanced communication and professional relationships. Clinical pharmacists’ indirect communication practices may hold important implications for patient safety in the context of medication use, and it is important to foster effective communication skills and an environment where all team members across hierarchies can feel comfortable speaking up to reduce error when problems are suspected. Also, the lack of institutional communication about managing drug formulary issues and related electronic nonformulary request processes was apparent in this study and merits further attention for both researchers and practitioners.     

Identifying opportunities for improved colorectal cancer screening in primary care

BACKGROUND: Although current recommendations advocate screening persons 50 years of age or older for colorectal cancer (CRC), actual screening practice is highly variable among primary care physicians (PCPs). Knowledge of the factors that influence whether or not screening is offered during a clinic visit is essential to develop effective screening strategies. METHODS: A cross-sectional telephone survey of one in four randomly selected patients aged 50 years or older (n = 400) attending a primary care clinic within an integrated health care system in central Texas was conducted. A survey of all PCPs (n = 32) at the practice sites was also administered. RESULTS: The visit type was an important determinant of whether CRC screening was discussed, with most discussion occurring during visits for physicals (P < 0.0001). This finding was corroborated by the physician survey. Patient age and education were also associated with a higher likelihood of having been offered CRC screening (P = 0.009 and 0.014, respectively). Patient race, gender, primary language, PCP, or clinics attended were not significantly associated with the discussion of CRC screening. CONCLUSIONS: Discussions regarding CRC screening are most likely to occur during preventive care visits. Thus, facilitating preventive visits especially for the elderly represents an opportunity to improve CRC screening rates in primary care practice.     

Whom Should We Profile? Examining Diabetes Care Practice Variation among Primary Care Providers,Provider Groups,and Health Care Facilities

OBJECTIVE: To evaluate the amount of variation in diabetes practice patterns at the primary care provider (PCP), provider group, and facility level, and to examine the reliability of diabetes care profiles constructed using electronic databases. DATA SOURCES/STUDY SETTING: Clinical and administrative data obtained from the electronic information systems at all facilities in a Department of Veterans Affairs' (VA) integrated service network for a study period of October 1997 through September 1998. STUDY DESIGN: This is a cohort study. The key variables of interest are different types of diabetes quality indicators, including measures of technical process, intermediate outcomes, and resource use. DATA COLLECTION/EXTRACTION METHODS: A coordinated registry of patients with diabetes was constructed by integrating laboratory, pharmacy, utilization, and primary care provider data extracted from the local clinical information system used at all VA medical centers. The study sample consisted of 12,110 patients with diabetes, 258 PCPs, 42 provider groups, and 13 facilities. PRINCIPAL FINDINGS: There were large differences in the amount of practice variation across levels of care and for different types of diabetes care indicators. The greatest amount of variance tended to be attributable to the facility level. For process measures, such as whether a hemoglobin A1c was measured, the facility and PCP effects were generally comparable. However, for three resource use measures the facility effect was at least six times the size of the PCP effect, and for inter-mediate outcome indicators, such as hyperlipidemia, facility effects ranged from two to sixty times the size of the PCP level effect. A somewhat larger PCP effect was found (5 percent of the variation) when we examined a "linked" process-outcome measure linking hyperlipidemia and treatment with statins). When the PCP effect is small (i.e., 2 percent), a panel of two hundred diabetes patients is needed to construct profiles with 80 percent reliability. CONCLUSIONS: little of the variation in many currently measured diabetes care practices is attributable to PCPs and, unless panel sizes are large, PCP profiling will be inaccurate. If profiling is to improve quality, it may be best to focus on examining facility-level performance variations and on developing indicators that promote specific, high-priority clinical actions.     

The Effect of Capitation on Switching Primary Care Physicians

Objective.  To examine the relationship between patient case-mix, utilization, primary care physician (PCP) payment method, and the probability that patients switch their PCPs.
Data Sources/Study Setting.  Administrative enrollment and claims/encounter data for 1994–1995 from four physician organizations.
Study Design.  We developed a conceptual model of patient switching behavior, which we used to guide the specification of multivariate logistic analyses focusing on interactions between patient case-mix, utilization, and PCP reimbursement methods.
Data Collection/Extraction Methods.  Claims data were aggregated to the encounter level; a switch was defined as a change in PCP since the previous encounter. The PCPs were reimbursed on either a capitated or fee-for-service (FFS) basis.
Principal Findings.  Patients with stable chronic conditions (Ambulatory Diagnostic Groups [ADG] 10) and capitated PCPs were 36 percent more likely to switch PCPs than similar patients with FFS PCPs, controlling for patient age and sex and physician fixed effects. When the number of previous encounters was included in the model, this relationship was no longer significant. Instead high utilizers with capitated PCPs were significantly more likely to switch PCPs than were similar patients with FFS PCPs.
Conclusions.  A patient's demographics and utilization are associated with the probability that the patient will switch PCPs. Capitated PCP payment was associated with higher rates of switching among high utilizers of health care resources. These findings raise concerns about the continuity and quality of care experienced by vulnerable patients in an era of changing financial incentives.     

A case study of early experience with implementation of collaborative care in the Veterans Health Administration

Primary care remains critically important for those who suffer from mental disorders. Although collaborative care, which integrates mental health services into primary care, has been shown to be more effective than usual care, its implementation has been slow and the experience of providers and patients with collaborative care is less well known. The objective of this case study was to examine the effects of collaborative care on patient and primary care provider (PCP) experiences and communication during clinical encounters. Participating physicians completed a self-administered visit reconstruction questionnaire in which they logged details of patient visits and described their perceptions of the visits and the influence of collaborative care. Audio recordings of visits were analyzed to assess the extent of discussion about colocated mental health services and visit time devoted to mental health topics. The main outcome measures were the extent of discussion and recommendation for collaborative care during clinical visits and providers' experiences based on their responses to the visit reconstruction questionnaire. Providers surveyed expressed enthusiasm about collaborative care and cited the time constraint of office visits and lack of specialty support as the main reasons for limiting their discussion of mental health topics with patients. Despite the availability of mental health providers at the same clinic, PCPs missed many opportunities to address mental health issues with their patients. Ongoing education for PCPs regarding how to conduct a "warm handoff" to colocated providers will need to be an integral part of the implementation of collaborative care.     

Effect of Primary Care Visits on the Demand for Specialty Care in Health Maintenance Organizations

Health maintenance organizations (HMOs) provide low cost access to primary care physicians (PCPs) in an effort to restrict expensive specialty use. Although managed care plans hope that low cost primary care will reduce specialist use, the theoretical effect of easing access to primary care on specialty use is unclear. Despite the importance of estimating the effect of PCP visits on specialty use, no previous studies have directly addressed this question at the enrollee level. This study examines the effect of visits to the PCP on the demand for episodes of specialty care in two health plans: a gatekeeper HMO and a point-of-service plan. Using person-level data, we estimate a generalized method of moments model of specialty episodes that accounts for the endogeneity of PCP visits within a count-data framework. We compare this model to three alternative models—an OLS model, a negative binomial model, and a two-stage least squares model. We find evidence that increases in primary care visits increase episodes of specialty care in both plans. We also find that the three alternative models yield biased but more efficient estimates compared to the generalized method of moments model.This revised version was published online in June 2005 with a corrected cover date.     

Ambulatory medical care utilization estimates for 2005

OBJECTIVE: This report presents statistics on ambulatory care visits to physician offices, hospital outpatient departments (OPDs), and hospital emergency departments (EDs) in the United States in 2005. Ambulatory medical care utilization is described in terms of patient, practice, facility, and visit characteristics. METHODS: Data from the 2005 National Ambulatory Medical Care Survey (NAMCS) and the National Hospital Ambulatory Medical Care Survey (NHAMCS) were combined to produce averaged annual estimates of ambulatory medical care utilization. RESULTS: Patients in the United States made an estimated 1.2 billion visits to physician offices and hospital OPDs and EDs, a rate of 4.0 visits per person annually. Between 1995 and 2005, population visit rates increased by about 20% in primary care offices, surgical care offices, and OPDs; 37% in medical specialty offices; and 7% in EDs. The aging of the population has contributed to increased volume of visits because older patients have higher visit rates. Visits by patients 40-59 years of age represented about 28.5 percent in 2005, compared with 23.9 percent in 1995. Black persons had higher visit rates than white persons to hospital OPDs and EDs, but lower visit rates to office-based primary care and to surgical and medical specialists. In the ED, the visit rate for patients with no insurance was about twice that of those with private insurance; whereas for all types of office-based care, the visit rates were higher for privately insured persons than for uninsured persons. About 29.4 percent of all ambulatory care visits were for chronic diseases and 25.2 percent were for preventive care, including checkups, prenatal care, and postsurgical care. The leading treatment provided at ambulatory care visits was medicinal with 71.3 percent of all visits having one or more medications prescribed, up by 10% since 1995 when encounters with drug therapy represented 64.9 percent of all visits. In 2005, 2.4 billion medications were prescribed or administered at these visits.     

Missed appointment rates in primary care: the importance of site of care

The objective was to determine whether race, language, or gender concordance between primary care providers (PCPs) and patients is associated with lower missed appointment rates in neighborhood health centers. An additional objective was to determine whether site of care is a determinant of missed appointment rates. In analyses of 74,120 follow-up visits by 13,882 patients, odds ratios for missing an appointment for patients who had language, race or gender concordance with their PCP were 0.90 (95% confidence interval [CI], 0.81-0.99), 0.84 (95% CI, 0.79-0.90) and 1.01 (95% CI, 0.95-1.07) respectively, after adjustment for age, insurance, language, individual PCP open access, sessions per week PCP in practice, and health center. Odds ratios for missing an appointment varied nearly three-fold, depending upon the particular site of care. Race and language concordance between patients and PCPs has only a modest effect on missed appointment rates. Receipt of primary care services at specific neighborhood health centers was the strongest predictor of missed appointment rates in this sample.     

Psychosocial problem disclosure by primary care patients.

The vast majority of psychologically distressed primary care patients present exclusively somatic concerns at the outsets of their visits. However, it is not known how often such patients subsequently disclose psychosocial problems to their primary care physicians (PCPs) and what variables predict such disclosures. Our objectives were to measure, among psychologically distressed primary care patients, the frequency of disclosure of psychosocial problems (disclosure), the effects of prior psychosocial inquiry (prior inquiry) by PCPs and various patient variables on disclosure, and the effect of disclosure on mental health problem recognition (recognition) by PCPs. The study was based in the practices of 69 community-based PCPs and involved 308 adult patients with 28-item General Health Questionnaire scores of 5 or greater, indicating significant psychological distress. Disclosure occurred during 51% of visits overall and 67% of visits with prior inquiry. The odds of disclosure were increased by prior inquiry (p < 0.001), greater physician-patient familiarity (p < 0.001) and greater severity of patient psychological distress (p < 0.001). Prior inquiry and physician-patient familiarity had a negative interaction (p < 0.05) of smaller size than either variable's main effect, so that their combined effect on disclosure exceeded the effect of either variable alone but was less than multiplicative. The estimated odds ratio for recognition given disclosure was 24.13 (95% confidence interval, 11.28-51.63) after adjustment for the effects of significant covariates. We conclude that if PCPs inquire, most psychologically distressed, somatically presenting patients will disclose psychosocial problems. Inquiry is particularly productive with unfamiliar patients. PCPs can engender a substantial increase in psychosocial disclosure simply by adding one or two questions about mood or interpersonal problems to their clinical interviews.     

Breast Cancer Screening for Patients of Rural Accountable Care Organization Clinics: A Multi-Level Analysis of Barriers and Facilitators

Not all women 50–74 years received biennial mammography and the situation is worse in rural areas. Accountable care organizations (ACO) emphasize coordinated care, use of electronic health system, and preventive quality measures and these practices may improve their patients’ breast cancer screening rate. Using medical record data of 8,347 women patients aged 50–74 years from eight rural ACO clinics in Nebraska, this study examined patient-, provider-, and county-level barriers and facilitators for breast cancer screening. A generalized estimating equations model was used to account for the correlation among patients from the same provider and county. The multi-level logistic regression results suggest that uninsured non-Hispanic Black patients were less likely to meet the biennial mammography screening guideline. Patients whose preferred language being English, having a preventive visit in the past 12 months, having one or more chronic conditions were more likely to meet the biennial mammography screening guideline. Patients with a primary care provider (PCP) that was male, without a medical doctor degree were less likely to screen biennially. Patients with a PCP that reviewed performance report quarterly, or manually checked patients’ mammography screening status during visits were more likely to screen biennially. Interestingly, patients whose PCP reported being reminded by a care coordination team were less likely to screen biennially. Patients living in counties with more PCPs were also more likely to screen biennially. The study findings suggest that efforts targeting individual and practice-level barriers could be most effective in improving mammography screening for these rural ACO patients.     

When Behavioral Health Concerns Present in Pediatric Primary Care: Factors Influencing Provider Decision-Making

Primary care providers (PCPs) frequently encounter behavioral health (BH) needs among their pediatric patients. However, PCPs report variable training in and comfort with BH, and questions remain about how and when PCPs address pediatric BH needs. Existing literature on PCP decisions to address pediatric BH in-office versus referring to subspecialty BH is limited and findings are mixed. Accordingly, this study sought to examine parameters and contextual factors influencing PCP decisions and practices related to BH care. Qualitative interview results with 21 PCPs in Maryland indicated that decisions about how and when to address pediatric BH concerns are influenced by the type BH service needed, patient characteristics, the availability of BH services in the community, and possibly PCPs’ perceptions of BH care as a distinct subspecialty. Findings suggest that efforts to support individual PCPs’ capacity to address BH within primary care must be balanced by efforts to expand the subspecialty BH workforce.     

Where are social workers co-located with primary care physicians?

Social workers are increasingly working in primary care clinics that provide Integrated Behavioral Healthcare (IBH) in which a patient’s physical, behavioral, and social determinants of health are addressed on a collaborative team. Co-location, where care is housed in the same physical space, is a key element of IBH. Yet, little is known about the rate of social workers co-located with primary care physicians (PCPs). To identify national rates of social worker co-location, data were drawn from the Centers for Medicare and Medicaid (CMS) National Plan and Provider Enumeration System (NPPES; n = 232,021 social workers, n = 380,690 PCPs). Practice addresses were geocoded and straight-line distances between practice locations of social workers and PCPs were calculated. More than 26% of social workers were co-located with a PCP. However, in rural settings only 21% were co-located (p < .001). Co-location also varied by PCP practice size, specialty, and state. This study serves as a benchmark of the growth of IBH and continued monitoring of co-location is needed to ensure social work workforce planning and training are aligned with changing models of care. Further, identifying mechanisms to support social work education, current providers, and health systems to increase IBH implementation is greatly needed.     

Increasing Primary Care Physician Support for and Promotion of Cancer Clinical Trials

Only 2.5%–3% of adult cancer patients participate in cancer clinical trials, yet about 20% of cancer patients are medically eligible to participate. Research suggests that the primary care provider (PCP) can influence a patient''s awareness of, and potentially, his or her decision to consider a clinical trial. To address low cancer clinical trial accrual rates, ‘Imi Hale Native Hawaiian Cancer Network partnered with The Queen''s Cancer Center to provide and evaluate education on clinical trials to Hawai‘i PCPs. The educational materials were developed from a national curriculum and tailored to local audiences. Objectives of the curriculum were to educate PCPs about common myths (attitudinal barriers) around clinical trials and suggest ways that PCPs can introduce the concept of clinical trials to their patients with cancer or suspicion of cancer. The curriculum was tested on 128 PCPs in 2012. Knowledge of the PCP''s role and their willingness to mention clinical trials were measured through a post-test immediately following the presentation, which 74 (58%) PCPs completed. The post-test results suggested an increase in awareness among PCPs of their potential role in cancer clinical trial accrual, and an increase in PCP willingness to mention clinical trials to their patients with suspicion of cancer or diagnosed with cancer. Although findings suggest that this intervention is useful in increasing PCP receptivity to promoting cancer clinical trials, more research is needed to test if increased willingness results in increased accrual of cancer patients into clinical trials in Hawai‘i.     

Primary care physician practice styles and patient care: Evidence from physician exits in Medicare

Primary care physicians (PCPs) provide frontline health care to patients in the U.S.; however, it is unclear how their practice styles affect patient care. In this paper, we estimate the long-lasting effects of PCP practice styles on patient health care utilization by focusing on Medicare patients affected by PCP relocations or retirements, which we refer to as “exits.” Observing where patients receive care after these exits, we estimate event studies to compare patients who switch to PCPs with different practice style intensities. We find that PCPs have large effects on a range of aggregate utilization measures, including physician and outpatient spending and the number of diagnosed conditions. Moreover, we find that PCPs have large effects on the quality of care that patients receive, and that all of these effects persist for several years. Our results suggest that switching to higher-quality PCPs could significantly affect patients’ longer-run health outcomes.     

The contribution of comprehensive geriatric assessment to primary care physicians

Background

To provide quality care to the growing number of older patients, primary care physicians (PCPs) will require support from geriatric specialists. Multidisciplinary comprehensive geriatric assessment (CGA) has been found to improve outcomes in older people. This study explored the contribution of CGA to the management of older patients by their PCPs; PCP attitudes to CGA; and PCP satisfaction with CGA.

Methods

Two hundred PCPs in an Israeli Preferred Provider Organization were interviewed as part of an evaluative study of the contribution of a national outpatient CGA program to older patients, their families and physicians.

Results

The main reasons for referral to CGA were cognitive impairment and rapid functional decline. Three domains described the contribution of CGA to PCPs: medical treatment, support in counseling patients, and treatment of cognitive impairment. About 69% of PCPs definitely agreed that CGA more fully addressed the physical, mental and social needs of patients than other consultative clinics. About half were very satisfied with the CGA staff’s attitudes to patients, their families and to the PCP.

Conclusions

CGA contributed significantly to the care provided to older patients by PCPs. The expansion of CGA services deserves consideration.

     

Access to Patient-Centered Medical Homes in Children with Sickle Cell Disease

To determine the proportion of children with sickle cell disease (SCD) followed in a subspecialty clinic with access to a primary care provider (PCP) exhibiting practice-level qualities of a patient-centered medical home (PCMH). We surveyed 200 parents/guardians of children with SCD using a 44-item tool addressing PCP access, caregiver attitudes toward PCPs, barriers to healthcare utilization, perceived disease severity, and satisfaction with care received in the PCP versus SCD clinic settings. Individual PCMH criteria measured were a personal provider relationship and medical care characterized as accessible, comprehensive and coordinated. Although 94 % of respondents reported a PCP for their child, there was greater variation in the proportion of PCPs who met other individual PCMH criteria. A higher proportion of PCPs met criteria for coordinated care when compared to accessible or comprehensive care. In multivariate models, transportation availability, lower ER visit frequency and greater PCP visit frequency were associated favorably with having a PCP meeting criteria for accessible and coordinated care. Child and respondent demographics and disease severity had no impact on PCMH designation. Average respondent satisfaction scores for the SCD clinic was higher, when compared to satisfaction scores for the PCP. For children with SCD, access to a PCP is not synonymous with access to a medical home. While specific factors associated with PCMH access may be identified in children with SCD, their cause and effect relationships need further study.