Quality assessment in primary military clinics of the Israel Defense Forces Northern Command

OBJECTIVE: To assess the quality of care provided in primary military clinics. METHODS: A standardized assessment tool was used, with medical record audits and tracers (minimal clinical criteria for proper care of common conditions), peer-review observations of medical encounters, assessments of organization and administration, and patient satisfaction and physicians' occupational stress questionnaires. RESULTS: Forty-three clinics and 113 physicians were assessed. Tracers were high for management of upper respiratory infections and low for low back pains and mental problems. The average encounter time was 9 minutes, and 25% of medical encounters resulted in referrals to specialists. Regular physicians performed better than reservists. Surgeons performed worst as primary health care providers. Female physicians did better than male physicians. The integration of new immigrant physicians was successful, and they expressed less occupational stress. Smaller clinics were better, with longer encounter times and better patient satisfaction scores. CONCLUSIONS: Quality assessment of primary health care is feasible in the military system, providing useful information for future improvement.     

Provider satisfaction in army primary care clinics

The job satisfaction of physicians, nurse practitioners, and physician assistants was assessed during the course of a multicenter study of Army primary care clinics. All providers in nine clinics at three medical centers who were engaged in adult or family care were invited to participate in the study. Questionnaires on job satisfaction and other practice style variables were completed by 26 physicians, 19 nurse practitioners, and 13 physician assistants (46, 76, and 41% of eligible providers, respectively). Analysis revealed a broad range of job satisfaction in the sample. However, average levels of job satisfaction were not significantly different across the three groups of primary care providers. Autonomy and collaboration were significant predictors of job satisfaction. It is clear that changes in health care systems that reduce, or appear to reduce, the primary care provider's autonomy in clinical matters are likely to reduce provider satisfaction as well.     

Physicians' perceptions of the status of adolescent health care within the military health system.

OBJECTIVE: To describe the nature of the health care delivered to dependent adolescents throughout the military and compare services provided in adolescent medicine clinics with those provided in other medical departments and clinics. METHOD: Questionnaires were sent to physicians in pediatrics, internal medicine, family practice, primary care, emergency care, and adolescent medicine at 101 randomly selected military treatment facilities. A subsample of experts was selected to provide facility-specific, informed, representative information on the care provided to adolescents. RESULTS: Sixty-six percent (N = 345) of physicians returned completed questionnaires, providing information on 100% of the facilities sampled. More than half of responders felt that adolescents avoided care in their department. Two-thirds of all physicians, and three-fourths of the expert subsample, believed that adolescents are best served within adolescent medicine clinics. The expert subsample reported that adolescents served in facilities with adolescent medicine clinics received broader services. Only 28% of the facilities sampled provided any specialized adolescent medicine services. CONCLUSION: The military health care system has made progress in providing care to adolescent dependents, but reaching larger numbers of adolescents requires additional efforts.     

Role of the battalion surgeon in the Iraq and Afghanistan War

The battalion surgeon is an invaluable asset to a deploying unit. The primary role of a battalion surgeon is to provide basic primary care medicine and combat resuscitation. Other expectations include health care screening, vaccinations, supervision of medics, and being a medical advisor to the unit's commander. As many physicians who fill this role previously worked at medical treatment facilities or medical centers without prior deployment experience, the objective of this article is to highlight some of the challenges a battalion surgeon may encounter before, during, and following deployment.     

Point-of-Care Virtual Radiology Consultations in Primary Care: A Feasibility Study of a New Model for Patient-Centered Care in Radiology

BackgroundThe goal of this study is to assess the value of point-of-care virtual consultations in radiology.MethodsWe conducted an institutional review board–approved feasibility study of video-based radiology consultations in an internal medicine primary care clinic at a quaternary academic medical center. The study included 3 primary care providers (PCPs) and enrolled 43 patients. Inclusion criteria consisted of the following: age > 18 years, English speaking, recent radiology examination at our institution, and patient consenting to participate. Patients completed a pre- and postvisit survey. PCPs completed a postvisit survey. Primary study end points included the effect on patient and provider satisfaction, effect on patient experience and understanding of medical condition, and impact on PCP’s management decisions. Statistical significance was assessed using Fisher’s exact test.ResultsOf the enrolled patients, 93% (n = 40 of 43) indicated that they were satisfied with the virtual consultation visit. The PCPs were satisfied with the virtual consultation in 97% of consultations (n = 42 of 43). In addition, 88% (n = 38 of 43) of patients indicated improved understanding of their medical condition as a result of the virtual consultation, and 91% of patients (n = 39 of 43) were interested in similar consultations in the future. The participating PCPs indicated that the consultation was helpful in their management decisions in 83% of visits. Patient’s interest in receiving their imaging results from radiologist increased from 56% to 88% when comparing pre– and post–virtual consultation survey results (P = .03).ConclusionInitial experience with virtual radiology consultations show high rates of patient and provider satisfaction. Virtual radiology consultations have the potential to advance radiology’s value in care delivery.     

The relation between good communication skills on the part of the physician and patient satisfaction in a military setting

OBJECTIVE: The objective of this study was to assess the correlation between patients' view of the consultation and the assessment of an auditing physician on the same consultation. METHODS: A prospective study in military clinics was conducted. A board-certified family physician made a real-time semistructured assessment of the medical consultation. At the end of it, the patient was asked to fill in the Consultation Satisfaction Questionnaire. The degree of correlation between patients' satisfaction from consultation and the scores given by the auditing physician was evaluated. RESULTS: Twelve primary care physicians were evaluated. A total of 117 (76.5%) of 153 patients returned their questionnaires. A positive correlation was found between physician's communication skills and general satisfaction (r = 0.614), professional care (r = 0.367), and depth of relationship (r = 0.275) calculated from the Consultation Satisfaction Questionnaire. No correlation was found between patient satisfaction and other consultation skills. CONCLUSIONS: Good communication skills may enhance patient satisfaction. It may be advisable to investigate whether a training program to enhance the physician's communication skills can improve patient satisfaction.     

Perspectives on the Value of Advanced Medical Imaging: A National Survey of Primary Care Physicians

PurposeTo understand perceptions of primary care physicians (PCPs) about the value of advanced medical imaging.MethodsA national quantitative survey of 500 PCPs was conducted using an online self-administered questionnaire. Questions focused on advanced medical imaging (CT, MRI, and PET) and its perceived impact on the delivery of patient care. Responses were stratified by physician demographics.ResultsLarge majorities of the PCPs indicated that advanced imaging increases their diagnostic confidence (441; 88%); provides data not otherwise available (451; 90%); permits better clinical decision making (440; 88%); increases confidence in treatment choices (438; 88%), and shortens time to definitive diagnosis (430; 86%]). Most (424; 85%) believe that patient care would be negatively affected without access to advanced imaging. PCPs whose clinical careers predated the proliferation of advanced imaging modalities (>20 years of practice) assigned higher value to advanced imaging on several dimensions compared with younger physicians whose training overlapped widespread technology availability.ConclusionsBy a variety of metrics, large majorities of PCPs believe that advanced medical imaging provides considerable value to patient care. Those whose careers predated the widespread availability of advanced imaging tended to associate it with even higher value.     

A Standardized Radiology Template Improves Incidental Adrenal Mass Follow-Up: A Prospective Effectiveness and Implementation Study

PurposeIncidental adrenal masses (IAMs) are common but rarely evaluated. To improve this, we developed a standardized radiology report recommendation template and investigated its implementation and effectiveness.MethodsWe prospectively studied implementation of a standardized IAM reporting template as part of an ongoing quality improvement initiative, which also included primary care provider (PCP) notifications and a straightforward clinical algorithm. Data were obtained via medical record review and a survey of radiologists. Outcomes included template adoption rates and acceptability (implementation measures), as well as the proportion of patients evaluated and time to follow-up (effectiveness outcomes).ResultsOf 4,995 imaging studies, 200 (4.0%) detected a new IAM. The standardized template was used in 54 reports (27.0%). All radiologists surveyed were aware of the template, and 91% affirmed that standardized recommendations are useful. Patients whose reports included the template were more likely to have PCP follow-up after IAM discovery compared with those with no template (53.7% versus 36.3%, P = .03). After adjusting for sex, current or prior malignancy, and provider ordering the initial imaging (PCP, other outpatient provider, or emergency department or inpatient provider), odds of PCP follow-up remained 2.0 times higher (95% confidence interval 1.02-3.9). Patients whose reports included the template had a shorter time to PCP follow-up (log-rank P = .018). PCPs ultimately placed orders for biochemical testing (35.2% versus 18.5%, P = .01), follow-up imaging (40.7% versus 23.3%, P = .02), and specialist referral (22.2% versus 4.8%, P < .01) for a higher proportion of patients who received the template compared with those who did not.ConclusionsUse of a standardized template to communicate IAM recommendations was associated with improved IAM evaluation. Our template demonstrated high acceptability, but additional strategies are necessary to optimize adoption.     

Nonclinical factors associated with primary care physicians’ ordering patterns of magnetic resonance imaging/computed tomography for headache

RATIONALE AND OBJECTIVES: The purpose of ordering an imaging test for headache, which is one of the most common reasons for patient consultation with a primary care physician (PCP), include medical indications as well as patient anxiety and medico-legal concerns. The impact of nonclinical factors on PCPs' ordering patterns of magnetic resonance imaging/computed tomography for patients presenting with a headache was examined. MATERIALS AND METHODS: A retrospective record review of all patients treated for headache as their primary complaint by a PCP from a multispecialty group practice associated with an 180,000-member Health Maintenance Organization during calendar year 2000 was examined. The practice included 18 clinics. Logistic regression was used to estimate the association between physician ordering patterns of imaging tests and patient, physician, and clinic setting characteristics. RESULTS: Of the total study subjects (n = 4,372), a magnetic resonance imaging/computed tomography imaging test was ordered for 5.3%. At their first encounter, patient's gender, site of care, and insurance status under the health care system's Health Maintenance Organization had statistically significant associations with the likelihood of imaging test orders. Female physicians were less likely to order an imaging test (OR = 0.65; 95% confidence interval, 0.39-1.08). For subsequent encounters, however, site of care was the only nonclinical factor that had a consistent association with the likelihood of having a magnetic resonance imaging/computed tomography ordered. CONCLUSION: These data show that a number of nonclinical factors may have been associated with having an imaging test ordered by a PCP when patients presented with a headache. These factors were more significant when the patient was being seen for the first time with this complaint.     

Development of a deployment course for graduating military internal medicine residents

Graduates of military internal medicine residency programs are required to have the necessary knowledge and skills to function as internists, military physicians, and military medical leaders. The global war on terrorism has increased the role internists are playing in combat theaters as they fill multiple different military medical positions including battalion, brigade, and division surgeons as well as physicians in echelon I, II, and III medical facilities. Along with general internists, internal medicine subspecialists, pediatricians, and family physicians also fill these roles. Although internal medicine training provides a broad-based knowledge to care for adults, it does not provide significant training in combat casualty care, detainee health care, or environmental health. To overcome many of these perceived shortfalls, we developed the 3-day deployment course for graduating internal medicine residents outlined in this article. Through a combination of didactic and hands-on training, militarily relevant medical knowledge and skills necessary to function at echelon I and II levels of care were provided. Residents uniformly accepted the course with measurable increase in their fund of knowledge at the completion of the course.     

Factors Affecting Adherence to Recommendations for Additional Imaging of Incidental Findings in Radiology Reports

ObjectiveTo determine the rate at which recommendations for additional imaging (RAIs) of incidental findings on CT are adhered to at a tertiary-care medical center and what factors influence adherence.MethodsWe used a radiology clinical informatics tool (mPower, Nuance Communications Inc, Burlington, Massachusetts) to identify RAIs in reports from all CT examinations performed at a tertiary-care medical center during a 6-month period. For those studies in which the RAI was for incidental findings, we reviewed the patients’ charts to determine if there was appropriate follow-up of the lesion in question.ResultsThe overall rate of adherence to RAIs was 39.1%, and in patients with a same-institution primary care provider (PCP), 56.8% (P < .0001). Adherence was higher in studies ordered in the outpatient setting (P < .0001) and in patients with a same-institution PCP (P < .0001). Among patients with a same-institution PCP, adherence was highest for outpatients (66.7%), followed by patients seen in the emergency department (46.0%) and inpatients (36.0%). Among outpatients, adherence was highest with PCPs (67%) followed by internal medicine subspecialties (50%) and surgery (38%).DiscussionThe rate of adherence to recommendations for additional imaging of incidental findings was 39.1% in this study and higher for patients with a same-institution PCP, studies ordered in the outpatient setting, and in studies ordered by PCPs.     

Survey of U.S. Army commanders' experiences with brigade/battalion surgeons at Fort Hood, Texas

This anonymous survey sent to every battalion and brigade commander at Fort Hood, Texas assessed the new concept of residency-trained operational physicians that had completed military unique curriculum series training. Commanders provided anonymous professional information about themselves and their assigned physicians and evaluated their physicians in 22 areas of medical and military competence using a linear scoring method from 2 (indicating poor) to 6 (indicating outstanding). Main effects and interaction effects were analyzed using multiple analysis of variance. The commanders' overall confidence in their physicians was 5.4, suggesting general satisfaction. Prior-service physicians were rated higher on several factors if the commander had combat experience. Non-prior-service physicians were rated the same on nearly all variables regardless of the commander's experience. Commanders with combat experience rated their assigned physicians significantly higher than did commanders without combat experience. Despite high ratings, several candid remarks suggest there is still room for improvement.     

Reason for referrals among military primary care physicians.

In order to assess the reasons for high referral rates to secondary medical care services in the Israel Defence Force-Medical Corps, we conducted a study in which 28 physicians in five primary care clinics took part. Seven hundred thirty-seven patients were referred to specialists. The referral reasons were learned from questionnaires filled in for each of these patients. The study shows that factors related to the physicians are important in determining when referral is made: Israeli medical graduates showed less confidence than their peer graduates outside of Israel. A possible explanation is that the Israeli graduates are better prepared for working in a scientific, sophisticated medical environment rather than the ambulatory primary care environment.     

Information needs of naval primary care providers and patients at sea

OBJECTIVE: To optimally practice medicine, and to live healthy lives, providers and patients need convenient access to authoritative information. The goal of this study was to determine the information needs of naval primary care providers and patients at sea to aid development of a digital health sciences library for naval primary care providers and patients. METHOD: A literature-based needs assessment was conducted from articles identified using MEDLINE searching and U.S. Navy health care information sources. Recurring medical problems/diseases/topics were identified and categorized. RESULTS: Eighty-one articles and books were reviewed and abstracted, representing a broad base of naval medicine. Twenty-one medical and surgical theme areas and 125 medical problems/diseases/topics were recurrently identified. CONCLUSIONS: The common naval medical problems identified are nearly identical to the common medical problems in the general population, have changed little from the 18th century, and were consistent with first-hand information from naval primary care providers.     

A survey of mild traumatic brain injury treatment in the emergency room and primary care medical clinics

This study surveyed health care providers about their evaluation and treatment of mild traumatic brain injury (TBI) in adults. We presented two vignettes describing mild TBI cases to staff in the emergency department (N = 22) and primary care clinics (N = 16) at Wilford Hall Air Force Medical Center and asked how they would evaluate and treat these patients. Most providers said they would assess visual changes, nausea/vomiting, headache, and neck pain. More emergency department personnel than primary care clinic providers would make referrals to different specialties, whereas more primary care clinic providers would schedule a follow-up appointment. Neither group of providers mentioned assessing common postconcussive symptoms of fatigue, emotional changes, and problems sleeping. Comparing findings to current literature suggest that added focus on emotional, cognitive and psychosocial factors, and education of the patient and family could improve early identification of mild TBI patients at risk for poor recovery.     

Survey on practice patterns in imaging utilization in patients with Crohn's disease

PurposeTo perform a survey-based assessment of imaging practice preferences in Crohn's disease (CD).MethodsAn internet-based questionnaire was sent to physicians involved in CD care. The questionnaire addressed the experience, practice patterns, choice of modality, and recent trends in imaging utilization.ResultsThe response rate was 7.57% (122/1598) with 43.8% of respondents involved in care of CD for ≥10 years. CT was mostly preferred by ED physicians, internists and primary care physicians, while MRI by gastroenterologists and pediatricians. Practitioners from non-teaching facilities had higher preference for CT (CT:42% andMR:27%), compared to teaching/academic hospitals (MR:45% and CT: 40%) (p = 0.06). MR was preferred by pediatric practitioners compared to physicians serving older age group of patients (>16 yrs) (p = 0.01). CT was preferred by physicians taking care of <50 patients/year (CT:37, MR:27, No preference = 19) and MR preferred by physicians serving ≥50 patients/year (CT:12, MR:21, No preference:3)(p = 0.02). CT/CT enterography was the most widely used exam (93.3%) and preferred modality for evaluation of acute CD exacerbation (87.7%), followed by assessment for new symptoms (73.7%) and extra-intestinal manifestations (61.3%). MR/MR enterography (58%) was more preferred for asymptomatic CD patients for disease surveillance.Nearly 80% of respondents reported a change in imaging preferences, 46.5% respondents indicating growing preference for MRI while 33.3% reported increasing preference for CT. 29.6% physicians reported a patient preference for MRI over CT (13%) with the most common factor for choice of MRI being fear of harmful effects of radiation (60.2%).ConclusionPhysician practices reported continued preference for CT in evaluation of patients with CD, particularly for evaluation of acute exacerbation, new symptoms or extra-intestinal manifestations. Physician providers with large practice volume, younger patient population and GI sub-specialty expertise report growing MRI utilization.     

A comprehensive and cost-effective preparticipation exam implemented on the World Wide Web

Mandatory preparticipation examinations (PPE) are labor intensive, offer little routine health maintenance and are poor predictors of future injury or illness. Our objective was to develop a new PPE for the Stanford University varsity athletes that improved both quality of primary and preventive care and physician time efficiency. This PPE is based on the annual submission, by each athlete, of a comprehensive medical history questionnaire that is then summarized in a two-page report for the examining physician. The questionnaire was developed through a search of MEDLINE from 1966 to 1997, review of PPE from 11 other institutions, and discussion with two experts from each of seven main content areas: medical and musculoskeletal history, eating, menstrual and sleep disorders, stress and health risk behaviors. Content validity was assessed by 10 sports medicine physicians and four epidemiologists. It was then programmed for the World Wide Web (http:// www.stanford.edu/dept/sportsmed/). The questionnaire demonstrated a 97 +/- 2% sensitivity in detecting positive responses requiring physician attention. Sixteen physicians administered the 1997/98 PPE; using the summary reports, 15 found improvement in their ability to provide overall medical care including health issues beyond clearance; 13 noted a decrease in time needed for each athlete exam. Over 90% of athletes who used the web site found it "easy" or "moderately easy" to access and complete. Initial assessment of this new PPE format shows good athlete compliance, improved exam efficiency and a strong increase in subjective physician satisfaction with the quality of screening and medical care provided. The data indicate a need for improvement of routine health maintenance in this population. The database offers opportunities to study trends, risk factors, and results of interventions.     

Various contract settings and their impact on the cost of medical services

OBJECTIVES: This study analyzes the effect of outsourcing healthcare on career soldiers in the Israel Defense Forces (IDF) in different settings, so as to develop a model for predicting per capita medical costs METHODS: Demographic information and data on healthcare utilization and costs were gathered from three computerized billing database systems: The IDF Medical Corps; a civilian hospital; and a healthcare fund, providing services to 3,746; 3,971; and 6,400 career soldiers, respectively. Visits to primary care physicians and specialists, laboratory and imaging exams, number of sick-leave days, and hospitalization days, were totaled for men and women separately for each type of clinic. A uniform cost was assigned to each type of treatment to create an average annual per capita cost for medical services of career soldiers. RESULTS: Significantly more visits were recorded to primary care physician and to specialists, as well as imaging examinations by Leumit Healthcare Services (LHS), than visits and tests in hospitals or in military clinics (p < 0.001). The number of referrals to emergency rooms and sick-leave days were lowest in the LHS as compared to the hospital and military clinics (p < 0.001). The medical cost per capita/year was lowest in LHS as well. CONCLUSIONS: Outsourcing primary care for career soldiers to a civilian healthcare fund represents a major cost effective change, lowest consumption and lower cost of medical care. Co-payment should be integrated into every agreement with the medical corps.     

A pilot study of clinical agreement in cardiovascular preparticipation examinations: how good is the standard of care?

OBJECTIVE: To evaluate the interobserver agreement between physicians regarding a abnormal cardiovascular assessment on athletic preparticipation examinations. DESIGN: Cross-sectional clinical survey. SETTING: Outpatient Clinic, United States Military Academy, West Point, NY. PARTICIPANTS: We randomly selected 101 out of 539 cadet-athletes presenting for a preparticipation examination. Two primary care sports medicine fellows and a cardiologist examined the cadets. INTERVENTIONS: After obtaining informed consent from all participants, all 3 physicians separately evaluated all 101 cadets. The physicians recorded their clinical findings and whether they thought further cardiovascular evaluation (echocardiography) was indicated. MAIN OUTCOME MEASURES: Rate of referral for further cardiovascular evaluation, clinical agreement between sports medicine fellows, and clinical agreement between sports medicine fellows and the cardiologist. RESULTS: Each fellow referred 6 of the 101 evaluated cadets (5.9%). The cardiologist referred none. Although each fellow referred 6 cadets, only 1 cadet was referred by both. The kappa statistic for clinical agreement between fellows is 0.114 (95% CI, -0.182 to 0.411). There was no clinical agreement between the fellows and the cardiologist. CONCLUSIONS: This pilot study reveals a low level of agreement between physicians regarding which athletes with an abnormal examination deserved further testing. It challenges the standard of care and questions whether there is a need for improved technologies or improved training in cardiovascular clinical assessment.