Chronic disease, prevention policy, and the future of public health and primary care

Globally, chronic disease and conditions such as diabetes, cardiovascular disease, depression and cancer are the leading causes of morbidity and mortality. Why, then, are public health efforts and programs aimed at preventing chronic disease so difficult to implement and maintain? Also, why is primary care—the key medical specialty for helping persons with chronic disease manage their illnesses—in decline? Public health suffers from its often being socially controversial, personally intrusive, irritating to many powerful corporate interests, and structurally designed to be largely invisible and, as a result, taken for granted. Primary care struggles from low reimbursements, relative to specialists, excessive paperwork and time demands that are unattractive to medical students. Our paper concludes with a discussion of why the need for more aggressive public health and redesigned primary care is great, will grow substantially in the near future, and yet will continue to struggle with funding and public popularity.     

Specialist and Generalist Care for Type 1 Diabetes Mellitus

The incidence of diabetes mellitus (both type 1 and type 2) is growing to epidemic proportions, with an expected combined worldwide prevalence of 220 million by the year 2010. A subsequent increase in the incidence of diabetes complications is likely to follow if present trends continue, placing an increased burden on already troubled healthcare systems. While there are many identified biologic mechanisms for the development of diabetes complications, there has been little exploration of healthcare provider issues and their contribution to these outcomes. One area of research with few data is the influence of diabetes specialty care on outcomes in type 1 diabetic patients. Evidence demonstrates that both process delivery and outcomes are better in individuals with typel diabetes who are cared for by diabetes specialists compared with generalists. For example, those receiving care from diabetes specialists were more likely to receive diabetes education, to be treated with intensive insulin therapy (>2 injections/day), and to receive an eye examination compared with those receiving generalist care. Additionally, lower rates of proliferative retinopathy were observed in those receiving specialist care. Recent evidence also demonstrates that there are lower incidences of neuropathy, overt nephropathy, and coronary artery disease in those patients who spend a higher proportion of the duration of their diabetes in specialist care. Based on these observations, it is recommended that attempts be made to replicate the favorable characteristics of specialty care in the primary care setting. Healthcare systems should ensure the availability of access to diabetes specialists, as well as ancillary healthcare professionals including diabetes educators, with increased emphasis placed on coordinated care.     

Electronic Consultations to Improve the Primary Care-Specialty Care Interface for Cardiology in the Medically Underserved: A Cluster-Randomized Controlled Trial

PURPOSE

Communication between specialists and primary care clinicians is suboptimal, and access to referrals is often limited, which can lead to lower quality, inefficiency, and errors. An electronic consultation (e-consultation) is an asynchronous, non-face-to-face consultation between a primary care clinician and a specialist using a secure electronic communication platform. The purpose of this study was to conduct a randomized controlled trial of e-consultations to test its efficacy and effectiveness in reducing wait times and improving access to specialty care.

METHODS

Primary care clinicians were randomized into a control (9 traditional) or an intervention (17 e-consultation) arm for referrals to cardiologists. Primary care clinicians were recruited from 12 practice sites in a community health center in Connecticut with mainly medically underserved patients. Two end points were analyzed with a Cox proportional hazards model where the hazard of either a visit or an e-consultation was linked to study arm, sex, race, and age.

RESULTS

Thirty-six primary care clinicians participated in the study, referring 590 patients. In total, 69% of e-consultations were resolved without a visit to a cardiologist. After adjusting for covariates, median days to a review for an electronic consultation vs a visit for control patients were 5 and 24, respectively. A review of 6-month follow-up data found fewer cardiac-related emergency department visits for the intervention group.

CONCLUSION

E-consultation referrals improved access to and timeliness of care for an underserved population, reduced overall specialty utilization, and streamlined specialty referrals without any increase in adverse cardiovascular outcomes. e-consultations are a potential solution for improving access to specialty care.     

Focus group investigation on expectations of elderly people from health care facilities and physicians

INTRODUCTION: While the elderly are intensive health care users, little is known about their expectations of various medical facilities and physicians. We investigated their views on advAntages and disadvantages of different medical settings. METHODS: We established four focus groups and surveyed elderly people living in a rural area accessible to local practitioner's offices, and community, regional, and university hospitals, The focus groups examined advantages and disadvantages of care from these facilities. A coding scheme was used to organize the data in thematic categories, In a mail survey, participants ranked the importance of specialty care; overall care; triage of patients; gentle personality; listening skills; and explanation skills, The data were analyzed for statistical differences between the various settings. RESULTS: Total of 41 elderly participated in focus groups, and 40 individuals (response rate 98%) returned statistical surveys. Advantages of care from a primary care doctor included continuity and physician accommodation of patients' preferences, while limited medical services and urgent access were disadvantages. Advantages of the community hospital included expanded medical facilities and having doctors easy to talk with, while disadvantages included lack of trust and frequent turnover. Advantages of larger facilities included extensive medical equipment, a broad range of departments and specialists, and more expert care. The survey revealed expectations for expert triage skills and familiarity with a doctor who is easy to talk with, particularly primary care doctor. DISCUSSION: These elderly subjects expect primary care and community doctors to be accessible and to exhibit excellent behavioral and communication skills, They expect more specialized and technical care in larger hospitals.     

Partnering urban academic medical centers and rural primary care clinicians to provide complex chronic disease care

Many of the estimated thirty-two million Americans expected to gain coverage under the Affordable Care Act are likely to have high levels of unmet need because of various chronic illnesses and to live in areas that are already underserved. In New Mexico an innovative new model of health care education and delivery known as Project ECHO (Extension for Community Healthcare Outcomes) provides high-quality primary and specialty care to a comparable population. Using state-of-the-art telehealth technology and case-based learning, Project ECHO enables specialists at the University of New Mexico Health Sciences Center to partner with primary care clinicians in underserved areas to deliver complex specialty care to patients with hepatitis C, asthma, diabetes, HIV/AIDS, pediatric obesity, chronic pain, substance use disorders, rheumatoid arthritis, cardiovascular conditions, and mental illness. As of March 2011, 298 Project ECHO teams across New Mexico have collaborated on more than 10,000 specialty care consultations for hepatitis C and other chronic diseases.     

Montana Primary Care Providers’ Access to and Satisfaction With Pediatric Specialists When Caring for Children With Special Health Care Needs

Purpose: Primary care providers (PCPs) of children with special health care needs (CSHCN) in rural areas face challenges in accessing specialty care to support a patient‐centered medical home. This study assessed the practice characteristics and attitudes regarding pediatric specialty care among Montana PCPs of CSHCN. Methods: We surveyed 433 Montana PCPs identified through a statewide registry. Demographic and practice information was collected, including the proportion of time spent on CSHCN care coordination. A 5‐point Likert scale was used to calculate mean need scores for each pediatric specialty, access to these specialties, and barriers to care. Results were analyzed separately for pediatricians and family physicians, as well as rural and urban providers, using λ2, t tests, and Mann‐Whitney tests. Results: Of the PCPs surveyed, 386 had a valid address and were currently practicing in Montana, 112 (29%) responded, and 91 provided care to CSHCN (averaged 29% of time spent in CSHCN care coordination). Child psychiatry (4.1) and developmental/behavioral pediatrics (3.7) were identified as the most needed specialties, yet they scored lowest in access to care (2.2 and 2.6, respectively). The most important rated specialist characteristics were quality (4.1), availability (3.5), and communication skills (2.8). Among the top barriers to care, lack of appropriate specialists was identified by 82% of PCPs. Conclusions: Specialty care delivery for CSHCN in rural areas such as Montana should focus on matching availability with the identified need for specialty services, and ensuring that systems of communication between PCPs and specialists support the care coordination function of PCPs.     

Primary care for HIV-exposed and infected children: translating progress into practice

Recent advances have changed the guidelines for diagnosing and managing pediatric human immunodeficiency virus (HIV) infection. HIV-exposed and HIV-infected children should be evaluated by, or in consultation with, pediatric HIV specialists. Primary care practitioners play a vital role in identification of infants and children at risk for HIV infection and can work collaboratively with pediatric HIV specialists to provide state-of-the-art care. With the use of perinatal zidovudine, perinatal transmission rates have been reduced to 3% to 4%, and they may be reduced even further by the use of combination antiretroviral therapy during pregnancy, viral load monitoring, and obstetric interventions. Diagnosis of HIV infection can be determined in all perinatally infected infants by 6 months of age. Combination antiretroviral therapy is the standard of care for HIV-infected children. It has become increasingly effective, but complex. Families living with HIV are affected by a number of psychosocial issues. Disclosure of HIV diagnosis to a child is an important clinical issue. As HIV-infected children grow older, medical and psychosocial issues may impact school performance. The plan of care to address specific needs of HIV-infected children should be a collaborative effort between the children, their families, the primary care team, and the multidisciplinary pediatric HIV specialty team.     

Collaborative care needs and preferences of primary care patients with multimorbidity

OBJECTIVE To explore the collaborative care needs and preferences in primary care patients with multiple chronic illnesses. DESIGN Focus groups utilizing a series of open-ended questions elicited self-identified problems, experiences in communicating with providers, self-management needs, and preferences for monitoring and follow-up. Responses were organized and interpreted in light of the essential elements of collaborative care for chronic illness. SETTING AND PARTICIPANTS Sixty patients having two or more chronic illnesses at eight geographically dispersed primary care clinics within the Veterans Health Administration in the United States. RESULTS Identified problems included poor functioning, negative psychological reactions, negative effects on relationships and interference with work or leisure. Polypharmacy was a major concern. Problematic interactions with providers and the health care system were also mentioned, often in relation to specialty care and included incidents in which providers had ignored concerns or provided conflicting advice. Most participants, however, expressed overall satisfaction with their care and appreciation of their primary care physicians. Knowledge and skills deficits interfered with self-management. Participants were willing to use technology for monitoring or educational purposes if it did not preclude human contact, and were receptive to non-physician providers as long as they were used to augment, not eliminate, a physician's care. CONCLUSIONS Findings are consistent with the basic tenets of patient-centred, collaborative care, and suggested that health care can be organized and delivered to meet the complex needs of patients with multimorbidity.     

Influence of residency training on occupational medicine practice patterns

OBJECTIVES: A relatively high proportion of occupational medicine (OM) specialists have not had formal residency training in OM. Members of the Western Occupational and Environmental Medicine Association, a professional organization of OM specialists, completed a postal questionnaire (160 of 561 members). METHODS: Educational background, practice setting, practice activities, and skills considered relevant were compared between those with and without formal training. RESULTS: Both groups had considerable focus in clinical care, musculoskeletal medicine, and workers' compensation. However, those with formal training practice in a broader variety of settings were less likely to have practiced another specialty, and used additional skills (toxicology, industrial hygiene, and epidemiology) in their practices. Formal education appears to create a greater diversity of skills and opportunities, but it does not appear to create a group of physicians disinterested in "front-line" occupational medicine practice. CONCLUSIONS: The data support the need for formal residency programs but also highlight the importance of access to formal training for midcareer physicians.     

Dropping the baton: specialty referrals in the United States

Context: In the United States, more than a third of patients are referred to a specialist each year, and specialist visits constitute more than half of outpatient visits. Despite the frequency of referrals and the importance of the specialty‐referral process, the process itself has been a long‐standing source of frustration among both primary care physicians (PCPs) and specialists. These frustrations, along with a desire to lower costs, have led to numerous strategies to improve the specialty‐referral process, such as using gatekeepers and referral guidelines. Methods: This article reviews the literature on the specialty‐referral process in order to better understand what is known about current problems with the referral process and what solutions have been proposed. The article first provides a conceptual framework and then reviews prior literature on the referral decision, care coordination including information transfer, and access to specialty care. Findings: PCPs vary in their threshold for referring a patient, which results in both the underuse and the overuse of specialists. Many referrals do not include a transfer of information, either to or from the specialist; and when they do, it often contains insufficient data for medical decision making. Care across the primary‐specialty interface is poorly integrated; PCPs often do not know whether a patient actually went to the specialist, or what the specialist recommended. PCPs and specialists also frequently disagree on the specialist's role during the referral episode (e.g., single consultation or continuing co‐management). Conclusions: There are breakdowns and inefficiencies in all components of the specialty‐referral process. Despite many promising mechanisms to improve the referral process, rigorous evaluations of these improvements are needed.     

Managed care and patient ratings of the quality of specialty care among patients with pain or depressive symptoms

Background  

Managed care efforts to regulate access to specialists and reduce costs may lower quality of care. Few studies have examined whether managed care is associated with patient perceptions of the quality of care provided by physician and non-physician specialists. Aim is to determine whether associations exist between managed care controls and patient ratings of the quality of specialty care among primary care patients with pain and depressive symptoms who received specialty care for those conditions.     

General competencies and accreditation in graduate medical education

Many have recommended changing the professional development of physicians. Concluding that further educational process specification was inadequate, the Accreditation Council for Graduate Medical Education (ACGME) decided to specify six general competencies of graduate medical education (GME): patient care; medical knowledge; practice-based learning and improvement; professionalism; interpersonal skills and communication; and systems-based practice. Coupling them with a developmental view of professional knowledge and skill acquisition, the ACGME invited further specification and development of desired learning from the extended medical specialty community, including the specialty boards. This collaborative process offers a model of the role accrediting agencies can play in fostering workforce developmental change.     

Motives and preferences of general practitioners for new collaboration models with medical specialists: a qualitative study

Background  

Collaboration between general practitioners (GPs) and specialists has been the focus of many collaborative care projects during the past decade. Unfortunately, quite a number of these projects failed. This raises the question of what motivates GPs to initiate and continue participating with medical specialists in new collaborative care models.     

Collaboration with general practitioners: preferences of medical specialists – a qualitative study

Background  

Collaboration between general practitioners (GPs) and specialists has been the focus of many collaborative care projects during the past decade. Unfortunately, quite a number of these projects failed. This raises the question of what motivates medical specialists to initiate and continue participating with GPs in new collaborative care models.     

Correlations of knowledge and preference of medical students for a specialty career: a case-study of youth health care

Background  

Medical students develop interest in a specialty career during medical school based on knowledge and clinical experience of different specialties. How valid this knowledge is and how this knowledge relates to the development of preference for a specialty is not known. We studied their "subjective" knowledge of a specialty (students' reported knowledge) with "objective" knowledge of it (students actual knowledge as compared to reports of specialists) and their preference for this specialty at different stages of education, and used youth health care as a case study.     

An online interprofessional learning resource for physicians, pharmacists, nurse practitioners, and nurses in long-term care: benefits, barriers, and lessons learned

The importance of collaborative practice in health care has been emphasized.1,21, 2 There is a critical need for convenient and flexible education opportunities that support the development of collaborative practice skills among the health care workforce. Consequently, the purpose of this project was to create and evaluate an online learning resource for physicians, nurses, nurse practitioners, and pharmacists working in long-term care that provided practitioners with the skills, knowledge, and motivation necessary to enhance their ability to act as an interprofessional team while providing clinical care. The Demand-Driven Learning Model 3 was used to guide the project. Findings revealed learners enjoyed the programme and acquired new skills and knowledge relating to collaborative practice that they transferred to their workplace resulting in higher levels of collaborative practice. The data did not reveal significant changes in the learners' attitudes towards collaborative practice; perhaps because the participants were early adopters and already had positive attitudes. Requests to change organizational structure to enhance collaborative practice were minimal, as was the impact of the resource on resident care. Given the short time frame from completion of the learning resource to the evaluation, this is perhaps not surprising as it is reasonable to expect that these types of changes will take time to take effect within the organization. Follow-ups at a later date are suggested.     

Antiretroviral therapy in critically ill patients: a French national study

SETTINGS: The HIV-positive population is still increasing because the incidence of the disease remains high while the effectiveness of highly active antiretroviral therapy (HAART) has dramatically reduced mortality. HIV infected patients have an increased life expectancy and are more readily admitted to intensive care units. METHOD: We conducted a nation-wide comparative study in France of how these patients are managed by ICU specialists, on one hand, and HIV specialists, on the other, to better understand the use of antiretroviral therapy in critically ill patients. RESULTS: The results show heterogeneous responses of ICU specialists with an important proportion of non decisive answers. The answers of HIV specialists are more homogeneous. There appears to be little or no cooperation between the two specialties. The CISIH (French centers for the information and care of human immunodeficiency) are rarely consulted. CONCLUSIONS: ICU specialists must be better informed on this rapidly evolving disease. Access to updated information or to an HIV specialists must be made easier. Studies should also be made on how HAART is employed in ICUs (pharmacology, pharmacodynamics...).     

Effects of insurance status on children's access to specialty care: a systematic review of the literature

Background  

The current climate of rising health care costs has led many health insurance programs to limit benefits, which may be problematic for children needing specialty care. Findings from pediatric primary care may not transfer to pediatric specialty care because pediatric specialists are often located in academic medical centers where institutional rules determine accepted insurance. Furthermore, coverage for pediatric specialty care may vary more widely due to systematic differences in inclusion on preferred provider lists, lack of availability in staff model HMOs, and requirements for referral. Our objective was to review the literature on the effects of insurance status on children's access to specialty care.