Physicians,the Affordable Care Act,and Primary Care: Disruptive Change or Business as Usual?

The Patient Protection and Affordable Care Act1 (ACA) presages disruptive change in primary care delivery. With expanded access to primary care for millions of new patients, physicians and policymakers face increased pressure to solve the perennial shortage of primary care practitioners. Despite the controversy surrounding its enactment, the ACA should motivate organized medicine to take the lead in shaping new strategies for meeting the nation’s primary care needs. In this commentary, we argue that physicians should take the lead in developing policies to address the primary care shortage. First, physicians and medical professional organizations should abandon their long-standing opposition to non-physician practitioners (NPPs) as primary care providers. Second, physicians should re-imagine how primary care is delivered, including shifting routine care to NPPs while retaining responsibility for complex patients and oversight of the new primary care arrangements. Third, the ACA’s focus on wellness and prevention creates opportunities for physicians to integrate population health into primary care practice.     

Yes, But It’s Somewhat Difficult-Managing End of Life Care in Primary Health Care

A qualitative study was undertaken to investigate the perceptions of General Practitioners regarding the management of older people with heart failure, particularly at the end of life. Semi-structured interviews were conducted with 30 General Practitioners in Auckland, New Zealand during 2008. Participants identified that the needs of older patients with heart failure could not be addressed in isolation from the wider issues which affect older people. This complexity influenced all components of patient need including the typical course of the disease, the provision of prognostic and end of life information, and how palliative care was provided, including referral to specialist services. Some participants also believed that older people??s palliative care management should be approached differently to that of younger people stating, for example, that they were concerned about the amount of information older people could take in. A model which takes into consideration the experiences of the older person and fits them into, not a ??dying model?? but a ??life model??, one that supports the natural transition to end of life is needed. A ??life planning model?? used early in the management of patients would be a useful way forward and one which would allow the integration of the different paradigms of cardiology, gerontology, palliative care and nursing.     

Do Internists,Pediatricians, and Psychiatrists Feel Competent in Obesity Care?

BACKGROUND  Physicians must effectively evaluate and treat obesity. To design a needs-driven curriculum intended to improve patient outcomes, physicians were surveyed about their self-perceived knowledge and skills. OBJECTIVE  The objective of this study was to determine the expressed needs of residents and faculty regarding obesity care training across three specialties. DESIGN  The study used a survey given to faculty and residents in General Internal Medicine, Pediatrics, and Psychiatry. METHODS  Survey questions were generated from comprehensive nutrition curriculum and clinical recommendations, administered online, and then organized around a validated behavioral health framework—the 5As (assess, advise, agree, assist, arrange). Analyses were conducted to evaluate differences in perceived knowledge and skills between specialties and across training levels. RESULTS  From an overall response rate of 65% (65 residents and 250 faculty members), nearly 20% reported inadequate competency in every item with 48% of respondents reporting an inability to adequately counsel patients about common treatment options. Internists reported the lowest competency in arranging referrals and follow-up. Psychiatrists reported the lowest competency in assessment skills. CONCLUSIONS  This survey demonstrated a critical need for training in specific areas of obesity care. The proposed curriculum targets these areas taking into consideration observed differences across specialties.     

Hypertensive Patients’ Race, Health Beliefs, Process of Care, and Medication Adherence

BACKGROUND African Americans have higher rates of hypertension and worse blood pressure (BP) control than Whites, and poorer medication adherence may contribute to this phenomenon. We explored associations among patients’ race, self-reported experiences with clinicians, attitudes and beliefs about hypertension, and ultimately, medication adherence, among a sample with no racial disparities in BP control, to determine what lessons we could learn from patients and providers in this setting. METHODS We recruited 793 White and African-American (58%) patients previously diagnosed with hypertension from 3 VA medical centers to participate in survey assessments of each of the above dimensions, subsequent to a primary care clinic visit. RESULTS African-American patients’ providers were significantly more active in advising and counseling about hypertension care and medication adherence. African-American patients indicated greater knowledge or heightened awareness of the importance of controlling their BP, but there were no race differences on a summary adherence measure. In multivariate models modeling medication adherence, race was not significant, but having been told to split one’s pills, believing one’s BP continues to be high, and having one’s provider discuss things to do to make it easier to take BP medications were each significantly associated with worse adherence, whereas having more confidence in one’s ability to take BP medications as prescribed was associated with better adherence (all p’s  ≤ .02). CONCLUSION When both physicians and patients take BP management seriously, disparities in BP adherence and control may be reduced.     

Differences Between Primary Care Physicians’ and Oncologists’ Knowledge,Attitudes and Practices Regarding the Care of Cancer Survivors

Background  

The growing number of cancer survivors combined with a looming shortage of oncology specialists will require greater coordination of post-treatment care responsibilities between oncologists and primary care physicians (PCPs). However, data are limited regarding these physicians’ views of cancer survivors’ care.     

Primary Care Clinicians’ Recognition and Management of Depression: A Model of Depression Care in Real-World Primary Care Practice

BACKGROUND

Depression is prevalent in primary care (PC) practices and poses a considerable public health burden in the United States. Despite nearly four decades of efforts to improve depression care quality in PC practices, a gap remains between desired treatment outcomes and the reality of how depression care is delivered.

OBJECTIVE

This article presents a real-world PC practice model of depression care, elucidating the processes and their influencing conditions.

DESIGN

Grounded theory methodology was used for the data collection and analysis to develop a depression care model. Data were collected from 70 individual interviews (60 to 70 min each), three focus group interviews (n?=?24, 2 h each), two surveys per clinician, and investigators’ field notes on practice environments. Interviews were audiotaped and transcribed for analysis. Surveys and field notes complemented interview data.

PARTICIPANTS

Seventy primary care clinicians from 52 PC offices in the Midwest: 28 general internists, 28 family physicians, and 14 nurse practitioners.

KEY RESULTS

A depression care model was developed that illustrates how real-world conditions infuse complexity into each step of the depression care process. Depression care in PC settings is mediated through clinicians’ interactions with patients, practice, and the local community. A clinician’s interactional familiarity (“familiarity capital”) was a powerful facilitator for depression care. For the recognition of depression, three previously reported processes and three conditions were confirmed. For the management of depression, 13 processes and 11 conditions were identified. Empowering the patient was a parallel process to the management of depression.

CONCLUSIONS

The clinician’s ability to develop and utilize interactional relationships and resources needed to recognize and treat a person with depression is key to depression care in primary care settings. The interactional context of depression care makes empowering the patient central to depression care delivery.     

Should Health Care Providers be Accountable for Patients’ Care Experiences?

Measures of patients’ care experiences are increasingly used as quality measures in accountability initiatives. As the prominence and financial impact of patient experience measures have increased, so too have concerns about the relevance and fairness of including them as indicators of health care quality. Using evidence from the Consumer Assessment of Healthcare Providers and Systems (CAHPS®) surveys, the most widely used patient experience measures in the United States, we address seven common critiques of patient experience measures: (1) consumers do not have the expertise needed to evaluate care quality; (2) patient “satisfaction” is subjective and thus not valid or actionable; (3) increasing emphasis on improving patient experiences encourages health care providers and plans to fulfill patient desires, leading to care that is inappropriate, ineffective, and/or inefficient; (4) there is a trade-off between providing good patient experiences and providing high-quality clinical care; (5) patient scores cannot be fairly compared across health care providers or plans due to factors beyond providers’ control; (6) response rates to patient experience surveys are low, or responses reflect only patients with extreme experiences; and (7) there are faster, cheaper, and more customized ways to survey patients than the standardized approaches mandated by federal accountability initiatives.KEY WORDS: patient satisfaction, performance measurement, quality assessment, patient-centered care     

Palliative Care in Pflegeheimen—

Palliative Care and the Hospice Movement meet many of the challenges nursing homes are currently faced with. There are different approaches dependent on the rules and culture of the national health care systems. The reviewed literature shows that Palliative Care in Nursing Homes lacks quality, especially in the care given to residents with dementia. Apart from that, a palliative culture in the organizations has to be developed. In this paper, central issues and topics for further research to improve Palliative Care in Nursing Homes are presented.     

American Association for Respiratory Care

 【网址】 http://www.aarc.org 
【类型】 专业机构 
美国呼吸护理协会（American Association for Respiratory Care，AARC）创建于1947年，是一个国际领先的非营利性组织，会员逾52 000人，主要由呼吸治疗师和辅助内科医师的护理从业者组成。协会由美国胸腔学会（ATS）、美国胸科医师学会（ACCP）和美国麻醉医师学 会（ASA）资助。 
AARC主办两种期刊：Respiratory Care和AARC Times Magazine，前者主要发表原始研究论文和专题病例报告，如胸部X摄影术、肺功能检测 和血气分析；后者为新闻实事杂志。 
AARC每年举办国际呼吸年会，吸引世界各地6000多位呼吸治疗师和相关从业人员聚会研讨。AARC每年还举办其它学术会议、教学项目和专题讨论会。 
AARC网站上提供大量信息资源，主要栏目如下：
（1）社区交流（Community）：提供多种渠道的促进学会与会员、会员与会员之间交流的平台，如专业人员与社会交流网点AARConnect、 AARC电子邮件列表、微博等。
（2）资源（Resources）：提供相关新闻和杂志的文档、AARC基准系统（AARC Benchmarking System）、重要政府网站的链接、AARC资助项 目、临床实践指南、图片库、政府政策和声明等。AARC基准系统供各呼吸病诊疗单位在线报告和相互比较有关数据，以准确数据支持诊治决 策。
（3）职业（Career）：提供工作信息、求职建议、呼吸治疗师相关介绍以及呼吸护理领域研究者、治疗师、学生和内科医生的真实生活和 科研视频。
（4）教育（Education）：为专业人员和学生提供重要的教育资源链接，以及相关教育项目目前开展的状态，包括AARC继续教育课程、学术 会议等链接。网站还提供呼吸护理相关学会和政府机构、卫生保健相关学会、专业期刊等网络资源的链接。
（中国医科大学医学信息学系黄亚明潘现伟 整理）     

Prevalence of Internalized HIV-Related Stigma Among HIV-Infected Adults in Care,United States, 2011–2013

HIV-infected U.S. adults have reported internalized HIV-related stigma; however, the national prevalence of stigma is unknown. We sought to determine HIV-related stigma prevalence among adults in care, describe which socio-demographic groups bear the greatest stigma burden, and assess the association between stigma and sustained HIV viral suppression. The Medical Monitoring Project measures characteristics of U.S. HIV-infected adults receiving care using a national probability sample. We used weighted data collected from June 2011 to May 2014 and assessed self-reported internalized stigma based on agreement with six statements. Overall, 79.1% endorsed ≥1 HIV-related stigma statements (n = 13,841). The average stigma score was 2.4 (out of a possible high score of six). White males had the lowest stigma scores while Hispanic/Latina females and transgender persons who were multiracial or other race had the highest. Although stigma was associated with viral suppression, it was no longer associated after adjusting for age. Stigma was common among HIV-infected adults in care. Results suggest individual and community stigma interventions may be needed, particularly among those who are <50 years old or Hispanic/Latino. Stigma was not independently associated with viral suppression; however, this sample was limited to adults in care. Examining HIV-infected persons not in care may elucidate stigma’s association with viral suppression.     

The Effects of Primary Care Physician Visit Continuity on Patients’ Experiences with Care

Background Visit continuity is important to patients and valued by physicians. However, it is virtually impossible for primary care physicians (PCPs) to provide care during every paneled patient visit. It remains unclear whether PCP visit discontinuity can be planned in a way that is least disruptive to patients’ experiences with care. Objective This study aims to clarify whether visit continuity affects patients’ experiences with primary care equally for all patients. Design From January 2004 through March 2005, a large multispecialty practice in Massachusetts administered the Ambulatory Care Experience Survey (ACES) monthly to a random sample of patients visiting each of 145 PCPs. The analytic sample includes 14,835 patients with 2 or more primary care visits over the 6 months before being surveyed. Usual Provider Continuity (UPC), an administratively based measure of PCP visit continuity, was calculated for all respondents. Multilevel regression models that accounted for the clustering of patients within physicians modeled the relationship between UPC and each ACES measure. Interaction effects between UPC and gender, education, self-rated health, and PCP–patient relationship duration were tested. Results Physician–patient interaction quality, including physician communication, knowledge of the patient, health promotion support, and organizational access were more strongly influenced by visit continuity among respondents in early stages of a PCP–patient relationship (P < 0.01) and with worse self-rated health (P < 0.01). Conclusions Improvements in physician–patient relationship quality can be achieved by targeting visit continuity improvement efforts to patients who benefit most, particularly those in early stages of a PCP–patient relationship and/or perceive their health as poor.     

Trends and Quality of Care in Outpatient Visits to Generalist and Specialist Physicians Delivering Primary Care in the United States, 1997–2010

BACKGROUND

Although many specialists serve as primary care physicians (PCPs), the type of patients they serve, the range of services they provide, and the quality of care they deliver is uncertain.

OBJECTIVE

To describe trends in patient, physician, and visit characteristics, and compare visit-based quality for visits to generalists and specialists self-identified as PCPs.

DESIGN

Cross-sectional study and time trend analysis.

DATA

Nationally representative sample of visits to office-based physicians from the National Ambulatory Medical Care Survey, 1997–2010.

MAIN MEASURES

Proportions of primary care visits to generalist and specialists, patient characteristics, principal diagnoses, and quality.

KEY RESULTS

Among 84,041 visits to self-identified PCPs representing an estimated 4.0 billion visits, 91.5 % were to generalists, 5.9 % were to medical specialists and 2.6 % were to obstetrician/gynecologists. The proportion of PCP visits to generalists increased from 88.4 % in 1997 to 92.4 % in 2010, but decreased for medical specialists from 8.0 % to 4.8 %, p?=?0.04). The proportion of medical specialist visits in which the physician self-identified as the patient’s PCP decreased from 30.6 % in 1997 to 9.8 % in 2010 (p?<?0.01). Medical specialist PCPs take care of older patients (mean age 61 years), and dedicate most of their visits to chronic disease management (51.0 %), while generalist PCPs see younger patients (mean age 55.4 years) most commonly for new problems (40.5 %). Obstetrician/gynecologists self-identified as PCPs see younger patients (mean age 38.3 p?<?0.01), primarily for preventive care (54.0 %, p?<?0.01). Quality of care for cardiovascular disease was better in visits to cardiologists than in visits to generalists, but was similar or better in visits to generalists compared to visits to other medical specialists.

CONCLUSIONS

Medical specialists are less frequently serving as PCPs for their patients over time. Generalist, medical specialist, and obstetrician/gynecologist PCPs serve different primary care roles for different populations. Delivery redesign efforts must account for the evolving role of generalist and specialist PCPs in the delivery of primary care.     

How Do Hospitalized Patients Feel About Resident Work Hours,Fatigue, and Discontinuity of Care?

BACKGROUND: Patient-centered care requires that physicians understand patients' perspectives. Since the resident work hour rules were instituted, little information is available about how patients perceive these issues. Our objectives were to explore patients' knowledge, concerns, and attitudes about resident work hours, fatigue, and continuity of inpatient care and to evaluate the association between patients' trust and satisfaction with these concerns and attitudes. METHODS: We conducted a cross-sectional survey of 134 internal medicine inpatients at 3 institutions including a tertiary care academic health center, a Veterans Affairs medical center, and a private community teaching hospital. RESULTS: Mean age was 59 (range, 24-90), with 60% men and 70% white. Most patients agreed (50%) or felt neutral (38%) toward resident work hours being limited. Patients estimated that residents worked 60 h per week but thought that they should work no more than 51 h per week (p < .01 for the difference). Twenty-seven percent of patients had some concern about fatigue in the residents, and 28% reported concern about how often hand-offs of care occurred. Factor analysis yielded 3 factors: "worried about discontinuity/fatigue," "attitude toward resident/nurse work hours," and "perceived resident/nurse fatigue." In multivariable analyses, the "worried about fatigue/discontinuity" factor significantly predicted trust and satisfaction, and the "perceived resident/nurse fatigue" factor also predicted satisfaction. CONCLUSIONS: Some inpatients are concerned about both fatigue in resident physicians and discontinuity of care. This may play a role in trust and satisfaction for patients. Taking steps to design systems to minimize fatigue and discontinuity would be ideal.     

Palliative Care Consultations for Heart Failure Patients: How Many,When, and Why?

ObjectiveIn preparation for development of a palliative care intervention for patients with heart failure (HF) and their caregivers, we aimed to characterize the HF population receiving palliative care consultations (PCCs).Methods and ResultsReviewing charts from January 2006 to April 2011, we analyzed HF patient data including demographic and clinical characteristics, Seattle Heart Failure scores, and PCCs. Using Atlas qualitative software, we conducted a content analysis of PCC notes to characterize palliative care assessment and treatment recommendations. There were 132 HF patients with PCCs, of which 37% were New York Heart Association functional class III and 50% functional class IV. Retrospectively computed Seattle Heart Failure scores predicted 1-year mortality of 29% [interquartile range (IQR) 19–45] and median life expectancy of 2.8 years [IQR 1.6–4.2] years. Of the 132 HF patients, 115 (87%) had died by the time of the audit. In that cohort the actual median time from PCC to death was 21 [IQR 3–125] days. Reasons documented for PCCs included goals of care (80%), decision making (24%), hospice referral/discussion (24%), and symptom management (8%).ConclusionsDespite recommendations, PCCs are not being initiated until the last month of life. Earlier referral for PCC may allow for integration of a broader array of palliative care services.