Physician Acceptance of a Physician‐Pharmacist Collaborative Treatment Model for Hypertension Management in Primary Care

Physician‐pharmacist collaborative care (PPCC) is effective in improving blood pressure (BP) control, but primary care provider (PCP) engagement in such models has not been well‐studied. The authors analyzed data from PPCC referrals to 108 PCPs, for patients with uncontrolled hypertension, assessing the proportion of referral requests approved, disapproved, and not responded to, and reasons for disapproval. Of 2232 persons with uncontrolled hypertension, PPCC referral requests were sent for 1516 (67.9%): 950 (62.7%) were approved, 406 (26.8%) were disapproved, and 160 (10.6%) received no response. Approval rates differed widely by PCP with a median approval rate of 75% (interquartile range, 41%–100%). The most common reasons for disapproval were: PCP prefers to manage hypertension (19%), and BP controlled per PCP (18%); 8% of cases were considered too complex for PPCC. Provider acceptance of a PPCC hypertension clinic was generally high and sustained but varied widely among PCPs. No single reason for disapproval predominated.     

Attitudes of Primary Care Providers and Recommendations of Home Blood Pressure Monitoring—DocStyles, 2010

To assess primary care providers' (PCPs) opinions related to recommending home blood pressure monitoring (HBPM) for their hypertensive patients, the authors analyzed a Web‐based 2010 DocStyles survey, which included PCPs' demographics, health‐related behaviors, recommendations on HBPM, views of patient knowledge, and use of continuing medical education. Of the 1254 PCPs who responded, 539 were family practitioners, 461 were internists, and 254 were nurse practitioners; 32% recommended HBPM to ≥90% of their patients and 26% recommended it to ≤40% of their patients. Nurse practitioners were significantly more likely to recommend HBPM than were internists (odds ratio, 0.55; 95% confidence interval, 0.40–0.78). The top reasons for not recommending HBPM were “patient can't afford it” and “patient doesn't need it.” A total of 20% of PCPs indicated that their patients were poor to lower middle class; these PCPs were less likely to recommend HBPM to their patients than were those PCPs with most patients in higher economic classes. Additional efforts are needed to provide education to providers, especially physicians, about the benefits of HBPM in improved and cost‐effective blood pressure control in the United States.     

Primary care provider perceptions of the effectiveness of two self-management support programs for vulnerable patients with diabetes

Background

Primary care providers (PCPs) in safety net settings face barriers to optimizing care for patients with diabetes. We conducted this study to assess PCPs'' perspectives on the effectiveness of two language-concordant diabetes self-management support programs.

Methods

One year postintervention, we surveyed PCPs whose patients with diabetes participated in a three-arm multiclinic randomized controlled trial comparing usual care (UC), weekly automated telephone self-management (ATSM) support with nurse care management, and monthly group medical visits (GMVs). We compared PCP perspectives on patient activation to create and achieve goals, quality of care, and barriers to care using regression models accounting for within-PCP clustering.

Results

Of 113 eligible PCPs caring for 330 enrolled patients, 87 PCPs (77%) responded to surveys about 245 (74%) enrolled patients. Intervention patients were more likely to be perceived by PCPs as activated to create and achieve goals for chronic care when compared with UC patients (standardized effect size, ATSM vs UC, +0.41, p = 0.01; GMV vs UC, +0.31, p = 0.05). Primary care providers rated quality of care as higher for patients exposed to ATSM compared to UC (odds ratio 3.6, p < 0.01). Compared with GMV patients, ATSM patients were more likely to be perceived by PCPs as overcoming barriers related to limited English proficiency (82% ATSM vs 44% GMV, p = 0.01) and managing medications (80% ATSM vs 53% GMV, p = 0.01).

Conclusions

Primary care providers perceived that patients receiving ATSM support had overcome barriers, participated more actively, and received higher quality diabetes care. These views of clinician stakeholders lend additional evidence for the potential to upscale ATSM more broadly to support PCPs in their care of diverse, multilinguistic populations.     

Leaving the practice: effects of primary care physician departure on patient care

BACKGROUND: Recent changes in the organization of health care services, coupled with rising rates of primary care physician (PCP) turnover, pose threats to the maintenance of a continuous patient-physician relationship. Little is known, however, about how PCP departure may affect patients' quality of health care. METHODS: Participants were adult patients whose PCPs left a large, multispecialty group practice from July 1, 1994, to June 30, 1996 (n = 3931), and adult patients of a set of matched PCPs who remained in the practice at least 2 years beyond the index PCPs departure dates (n = 8009). We compared the following measures of quality of care: adherence to recommended screening guidelines, adequacy of blood pressure and glycemic control in patients with hypertension and/or diabetes mellitus, and use of urgent care and emergency department services. RESULTS: Among the women who received a mammogram in the 2-year baseline period, a higher proportion of those whose PCP departed did not continue to receive mammograms, although the difference did not reach statistical significance (8.4% vs 5.1%; P =.08). For patients who had screening Papanicolaou smears or fecal occult blood testing during the baseline period, there was no significant difference between study and control groups in the likelihood that patients discontinued screening during the follow-up period (10.9% vs 10.7%; P =.93 and 28.8% vs 25.3%; P =.93, respectively). Similarly, diabetic patients of departed PCPs did not have higher risk of worsening glycemic control (31.7% vs 28.9%; P =.46); and hypertensive patients of departed PCPs actually had lower risks of worsening blood pressure control (16.5% vs 22.5%; P =.02). There was no difference in use of urgent care or emergency department services between patient groups. CONCLUSIONS: In this multispecialty group practice, patients of departed PCPs experienced little or no decrease in quality of care measures for routine screening, management of chronic disease, and use of urgent care and emergency department services.     

The Role of Primary Care Physicians in Cancer Care

BACKGROUND  The demand for oncology services in the United States (US) is increasing, whereas a shortage of oncologists looms. There is the need for a better understanding of the involvement of primary care physicians (PCPs) in cancer care. OBJECTIVE  To characterize the role of PCPs in cancer care, compare it with that of oncologists, and identify factors explaining greater PCP involvement in cancer care. DESIGN  National survey of physicians caring for cancer patients conducted by the Cancer Care Outcomes Research and Surveillance Consortium. PARTICIPANTS  1694 PCPs; 1621 oncologists. MEASUREMENTS  Questionnaires mailed during 2005 and 2006 examined the participation of physicians in 12 aspects of care for cancer patients. MAIN RESULTS  Over 90% of PCPs fulfilled general medical care roles for patients with cancer such as managing comorbid conditions, chronic pain, or depression; establishing do-not-resuscitate status; and referring patients to hospice. Oncologists were less involved in these roles. Determining the treatment preferences of individual patients and deciding on the use of surgery were the only cancer care roles in which ≥50% of PCPs participated. Twenty-two percent of PCPs reported no direct involvement in cancer care roles while 19% reported heavy involvement. PCPs who were aged ≥50 years, were internists or geriatricians, taught medical students, saw more cancer patients, or experienced referral barriers fulfilled more roles. Rural practice location was not associated with greater PCP involvement in cancer care. CONCLUSIONS  PCPs across the US have an active role in cancer patient management. Determining the optimal interface between PCPs and oncologists in delivering and coordinating cancer care is an important area for future research.     

Community Physician Education in Geriatrics: Applying the Assessing Care of Vulnerable Elders Model with a Multisite Primary Care Group

Providing practicing physicians with effective education that leads to better patient outcomes remains challenging. In 2003, the University of Cincinnati College of Medicine developed a comprehensive program to enhance practicing physician geriatric medicine education based on the Assessing the Care of Vulnerable Elders model. The program was implemented with a large, multisite primary care group based in the greater Cincinnati area and was designed to increase physicians' clinical skills and assist them in implementing new office and system strategies that could improve the quality of care for their older patients. Four topic areas were chosen: medication management, falls and mobility, urinary incontinence, and dementia. A multifaceted physician education program was developed for each topic area, with lunch‐time, in‐office, geriatrician‐led presentations as the primary intervention. Over a 4‐year period (2004–2007), more than 60 physicians in 16 primary care practices attended 107 teaching sessions. The value of the presentation content, quality of the presentations, and perception of meeting the primary care physicians' (PCPs') educational needs were each rated at 3.8 or above (4=excellent). Between 80% and 92% of the PCPs planned to make a change in their practice behavior as a result of the training, but only two offices initiated formal quality improvement projects. During the teaching sessions, the PCPs were provided with screening tools to identify “at risk” patients, assessment chart templates, and community resource and patient education materials. The application of a modified version of the ACOVE model to reach a large group of primary care physicians is possible and may be one strategy to improve the assessment and management of geriatric syndromes.     

Patient Experiences with Coordination of Care: The Benefit of Continuity and Primary Care Physician as Referral Source

BACKGROUND  Coordination across a patient’s health needs and providers is important to improving the quality of care. OBJECTIVES  (1) Describe the extent to which adults report that their care is coordinated between their primary care physician (PCP) and specialists and (2) determine whether visit continuity with one’s PCP and the PCP as the referral source for specialist visits are associated with higher coordination ratings. DESIGN  Cross-sectional study of the 2007 Health Tracking Household Survey. PARTICIPANTS  A total of 3,436 adults with a PCP and one or more visits to a specialist in the past 12 months. MEASUREMENTS  Coordination measures were patient perceptions of (1) how informed and up to date the PCP was about specialist care received, (2) whether the PCP talked with the patient about what happened at the recent specialist visit and (3) how well different doctors caring for a patient’s chronic condition work together to manage that care. RESULTS  Less than half of respondents (46%) reported that their PCP always seemed informed about specialist care received. Visit continuity with the PCP was associated with better coordination of specialist care. For example, 62% of patients who usually see the same PCP reported that their PCP discussed with them what happened at their recent specialist visit vs. 48% of those who do not usually see the same PCP (adjusted percentages, p < 0.0001). When a patient’s recent specialist visit was based on PCP referral (vs. self-referral or some other source), 50% reported that the PCP was informed and up to date about specialist care received (vs. 35%, p < 0.0001), and 66% reported that their PCP discussed with them what happened at their recent specialist visit (vs. 47%, p < 0.0001). CONCLUSIONS  Facilitating visit continuity between the patient and PCP, and encouraging the use of the PCP as the referral source would likely enhance care coordination.     

Attention-deficit/hyperactivity disorder in adults: a survey of current practice in psychiatry and primary care

BACKGROUND: Recognition and treatment of attention-deficit/hyperactivity disorder (ADHD) in adults in psychiatry and primary care have faced many obstacles. METHODS: Review by 50 psychiatrists and 50 primary care practitioners (PCPs) of 537 and 317 medical records, respectively, of adults diagnosed as having ADHD. Information on other psychiatric disorders, time of onset of ADHD, source of referral, use of referrals for diagnosis, ADHD treatment, and use of drug holidays was recorded. RESULTS: Forty-five percent of the patient records reviewed by psychiatrists and 65% reviewed by PCPs indicated previous diagnoses of ADHD. Only 25% of the adults with ADHD had been first diagnosed as having the disorder in childhood or adolescence. A diagnosis of ADHD was the initial cause for referral in 80% of psychiatric patients and 60% of PCP patients. Most patients with previously diagnosed and undiagnosed ADHD were self-referred. Among patients who had not received a prior diagnosis, 56% complained about ADHD symptoms to other health professionals without being diagnosed; PCPs were the least aggressive in diagnosing ADHD. In psychiatric and PCP settings, there was a statistical difference in the use of pharmacotherapy (91% vs 78%, respectively) and the proportion of patients taking drug holidays (24% vs 17%, respectively); most drug holidays were initiated by the patient (57%). Stimulants were the treatment of choice for adult ADHD (84% treated with stimulants). CONCLUSION: Data contained within this medical record review suggest that adult ADHD is a substantial source of morbidity in both psychiatric and PCP settings.     

Processes and Outcomes of Congestive Heart Failure Care by Different Types of Primary Care Models

Background

Having nurse practitioners (NPs) as primary care providers for patients with congestive heart failure (CHF) is 1 way to address the growing shortage of primary care physicians (PCPs).

Recognition of patient referral desires in an academic managed care plan

OBJECTIVE: To determine the frequency and determinants of provider nonrecognition of patients’ desires for specialist referral. DESIGN: Prospective study. SETTING: Internal medicine clinic in an academic medical center providing primary care to patients enrolled in a managed care plan. PARTICIPANTS: Twelve faculty internists serving as primary care providers (PCPs) for 856 patient visits. MEASUREMENTS AND MAIN RESULTS: Patients were given previsit and postvisit questionnaires asking about referral desire and visit satisfaction. Providers, blinded to patients’ referral desire, were asked after the visit whether a referral was discussed, who initiated the referral discussion, and whether the referral was indicated. Providers failed to discuss referral with 27% of patients who indicated a definite desire for referral and with 56% of patients, who indicated a possible desire for referral. There was significant variability in provider recognition of patient referral desire. Recognition is defined as the provider indicating that a referral was discussed when the patient marked a definite or possible desire for referral. Provider recognition improved significantly (P<.05), when the patient had more than one referral desire, if the patient or a family member was a health care worker and when the patient noted a definite desire versus a possible desire for referral. Patients were more likely (P<.05) to initiate a referral discussion when they had seen the PCP previously and had more than one referral desire. Of patient-initiated referral requests, 14% were considered “not indicated” by PCPs. Satisfaction with care did not differ in patients with a referral desire that were referred and those that were nor referred. CONCLUSIONS: These PCPs frequently failed to explicitly recognize patients’ referral desires. Patients were more likely to initiate discussions of a referral desire when they saw their usual PCP and had more than a single referral desire. This work was funded by University Hospital Board of Directors, Denver, Colo.     

Predictors of Primary Care Management of Depression in the Veterans Affairs Healthcare System

BACKGROUND

Primary care providers (PCPs) vary in skills to effectively treat depression. Key features of evidence-based collaborative care models (CCMs) include the availability of depression care managers (DCMs) and mental health specialists (MHSs) in primary care. Little is known, however, about the relationships between PCP characteristics, CCM features, and PCP depression care.

OBJECTIVE

To assess relationships between various CCM features, PCP characteristics, and PCP depression management.

DESIGN

Cross-sectional analysis of a provider survey.

PARTICIPANTS

180 PCPs in eight VA sites nationwide.

MAIN MEASURES

Independent variables included scales measuring comfort and difficulty with depression care; collaboration with a MHS; self-reported depression caseload; availability of a collocated MHS, and co-management with a DCM or MHS. Covariates included provider type and gender. For outcomes, we assessed PCP self-reported performance of key depression management behaviors in primary care in the past 6 months.

KEY RESULTS

Response rate was 52 % overall, with 47 % attending physicians, 34 % residents, and 19 % nurse practitioners and physician assistants. Half (52 %) reported greater than eight veterans with depression in their panels and a MHS collocated in primary care (50 %). Seven of the eight clinics had a DCM. In multivariable analysis, significant predictors for PCP depression management included comfort, difficulty, co-management with MHSs and numbers of veterans with depression in their panels.

CONCLUSIONS

PCPs who felt greater ease and comfort in managing depression, co-managed with MHSs, and reported higher depression caseloads, were more likely to report performing depression management behaviors. Neither a collocated MHS, collaborating with a MHS, nor co-managing with a DCM independently predicted PCP depression management. Because the success of collaborative care for depression depends on the ability and willingness of PCPs to engage in managing depression themselves, along with other providers, more research is necessary to understand how to engage PCPs in depression management.     

Communication breakdown in the outpatient referral process

OBJECTIVE: To evaluate primary care and specialist physicians' satisfaction with interphysician communication and to identify the major problems in the current referral process. DESIGN: Surveys were mailed to providers to determine satisfaction with the referral process; then patient-specific surveys were e-mailed to this group to obtain real-time referral information. SETTING: Academic tertiary care medical center. PARTICIPANTS: Attending-level primary care physicians (PCPs) and specialists. MEASUREMENTS AND MAIN RESULTS: The response rate for mail surveys for PCPs was 57% and for specialists was 51%. In the mail survey, 63% of PCPs and 35% of specialists were dissatisfied with the current referral process. Respondents felt that major problems with the current referral system were lack of timeliness of information and inadequate referral letter content. Information considered important by recipient groups was often not included in letters that were sent. The response rate for the referral specific e-mail surveys was 56% for PCPs and 53% for specialists. In this e-mail survey, 68% of specialists reported that they received no information from the PCP prior to specific referral visits, and 38% of these said that this information would have been helpful. In addition, four weeks after specific referral visits, 25% of PCPs had still not received any information from specialists. CONCLUSIONS: Substantial problems were present in the referral process. The major issues were physician dissatisfaction, lack of timeliness, and inadequate content of interphysician communication. Information obtained from the general survey and referral-specific survey was congruent. Efforts to improve the referral system could improve both physician satisfaction and quality of patient care.     

Dementia undiagnosed in poor older adults with functional impairment

OBJECTIVES: To identify variables associated with diagnosing dementia in poor older adults by comparing older people with dementia who were diagnosed by their primary care physicians (PCPs) with those not diagnosed by their PCP.
DESIGN: Observational study.
SETTING: Community-based, in-home cognitive assessment program.
PARTICIPANTS: Four hundred eleven adults aged 55 and older with cognitive impairment.
MEASUREMENTS: Instrumental activities of daily living (IADLs), activities of daily living (ADLs), Mini-Mental State Examination, Short Blessed Memory Orientation and Concentration Test, and Clinical Dementia Rating.
RESULTS: Alzheimer's disease was the most common diagnosis in this group of primarily African-American (73%) older people. Of the 411 participants, 232 (56%) were not diagnosed by their PCP. Participants without a previous diagnosis were older (mean age 81.7 vs 78.7, P =.01), more independent in IADLs ( P <.001), and more likely to live alone ( P =.001) than persons diagnosed by their PCP. Of the 201 who lived alone, 66% were not diagnosed with dementia by their PCP. Variables associated with PCP diagnosis were more severe cognitive impairment ( P <.001), spouse caregiver ( P =.009), younger age ( P =.02) and care from a university-based PCP ( P =.04).
CONCLUSION: Persons with dementia who were older and lived alone were less likely to be diagnosed by their PCP. Although persons not diagnosed by their PCP had less cognitive impairment, they had substantial impairment in activities, including handling finances, cooking, and managing medications.     

Primary Care of the Renal Transplant Patient

There has been a remarkable rise in the number of kidney transplant recipients (KTR) in the US over the last decade. Increasing use of potent immunosuppressants, which are also potentially diabetogenic and atherogenic, can result in worsening of pre-existing medical conditions as well as development of post-transplant disease. This, coupled with improving long-term survival, is putting tremendous pressure on transplant centers that were not designed to deliver primary care to KTR. Thus, increasing numbers of KTR will present to their primary care physicians (PCP) post-transplant for routine medical care. Similar to native chronic kidney disease patients, KTRs are vulnerable to cardiovascular disease as well as a host of other problems including bone disease, infections and malignancies. Deaths related to complications of cardiovascular disease and malignancies account for 60–65% of long-term mortality among KTRs. Guidelines from the National Kidney Foundation and the European Best Practice Guidelines Expert Group on the management of hypertension, dyslipidemia, smoking, diabetes and bone disease should be incorporated into the long-term care plan of the KTR to improve outcomes. A number of transplant centers do not supply PCPs with protocols and guidelines, making the task of the PCP more difficult. Despite this, PCPs are expected to continue to provide general preventive medicine, vaccinations and management of chronic medical problems. In this narrative review, we examine the common medical problems seen in KTR from the PCP’s perspective. Medical management issues related to immunosuppressive medications are also briefly discussed.     

Revisiting the Time Needed to Provide Adult Primary Care

BackgroundMany patients do not receive guideline-recommended preventive, chronic disease, and acute care. One potential explanation is insufficient time for primary care providers (PCPs) to provide care.ObjectiveTo quantify the time needed to provide 2020 preventive care, chronic disease care, and acute care for a nationally representative adult patient panel by a PCP alone, and by a PCP as part of a team-based care model.DesignSimulation study applying preventive and chronic disease care guidelines to hypothetical patient panels.ParticipantsHypothetical panels of 2500 patients, representative of the adult US population based on the 2017–2018 National Health and Nutrition Examination Survey.Main MeasuresThe mean time required for a PCP to provide guideline-recommended preventive, chronic disease and acute care to the hypothetical patient panels. Estimates were also calculated for visit documentation time and electronic inbox management time. Times were re-estimated in the setting of team-based care.Key ResultsPCPs were estimated to require 26.7 h/day, comprising of 14.1 h/day for preventive care, 7.2 h/day for chronic disease care, 2.2 h/day for acute care, and 3.2 h/day for documentation and inbox management. With team-based care, PCPs were estimated to require 9.3 h per day (2.0 h/day for preventive care and 3.6 h/day for chronic disease care, 1.1 h/day for acute care, and 2.6 h/day for documentation and inbox management).ConclusionsPCPs do not have enough time to provide the guideline-recommended primary care. With team-based care the time requirements would decrease by over half, but still be excessive.Supplementary InformationThe online version contains supplementary material available at 10.1007/s11606-022-07707-x.KEY WORDS: Team-based care, Primary care, Preventive care, Chronic disease care, Population health     

The diagnosis of heart failure in European primary care: The IMPROVEMENT Programme survey of perception and practice

OBJECTIVE: To examine European primary care physicians (PCPs) views on diagnosis of heart failure and compare perceptions with actual practice. DESIGN: Semi-structured PCP interviews and case note review on a random sample of heart failure patients. PARTICIPANTS: 1363 primary care physicians from 14 countries and 11,062 patient notes. MAIN OUTCOME MEASURES: Perceptions of PCPs compared to actual performance in heart failure (HF) diagnosis. RESULTS: Over 50% of patients with HF were above 70 years of age. Most subjects presented with typical clinical symptoms and objective signs of HF. In 50% of cases, HF was mainly diagnosed by PCPs. New York Heart Association classification was used by 50% of physicians. Electrocardiogram and chest X-ray were the most used diagnostic tests (90% and 84% respectively). PCPs considered echocardiography as having low diagnostic value, with only 48% routine usage. However, in actual practice echocardiography was used in 82% of diagnoses. Systolic dysfunction was observed in 51% HF subjects, but only 50% of physicians would differentiate systolic from diastolic heart failure. CONCLUSIONS: There was low use of NYHA classification (which denotes symptom severity) and differentiation between systolic and diastolic causes (which determines treatment strategies).     

Assessing Care of Vulnerable Elders—Alzheimer's Disease: A Pilot Study of a Practice Redesign Intervention to Improve the Quality of Dementia Care

OBJECTIVES: To determine whether a practice redesign intervention coupled with referral to local Alzheimer's Association chapters can improve the quality of dementia care. DESIGN: Pre–post intervention. SETTING: Two community‐based physician practices. PARTICIPANTS: Five physicians in each practice and their patients aged 75 and older with dementia. INTERVENTION: Adaptation of the Assessing Care of Vulnerable Elders (ACOVE)‐2 intervention (screening, efficient collection of clinical data, medical record prompts, patient education and empowerment materials, and physician decision support and education). In addition, physicians faxed referral forms to local Alzheimer's Association chapters, which assessed patients, provided counseling and education, and faxed information back to the physicians. MEASUREMENTS: Audits of pre‐ (5 per physician) and postintervention (10 per physician) medical records using ACOVE‐3 quality indicators for dementia to measure the quality of care provided. RESULTS: Based on 47 pre‐ and 90 postintervention audits, the percentage of quality indicators satisfied rose from 38% to 46%, with significant differences on quality indicators measuring the assessment of functional status (20% vs 51%), discussion of risks and benefits of antipsychotics (32% vs 100%), and counseling caregivers (2% vs 30%). Referral of patients to Alzheimer's Association chapters increased from 0% to 17%. Referred patients had higher quality scores (65% vs 41%) and better counseling about driving (50% vs 14%), caregiver counseling (100% vs 15%), and surrogate decision‐maker specification (75% vs 44%). Some quality indicators related to cognitive assessment and examination did not improve. CONCLUSION: This pilot study suggests that a practice‐based intervention can increase referral to Alzheimer's Association chapters and improve quality of dementia care.