Patients Report Better Satisfaction with Part-Time Primary Care Physicians,Despite Less Continuity of Care and Access

BACKGROUND

The growing number of primary care physicians (PCPs) reducing their clinical work hours has raised concerns about meeting the future demand for services and fulfilling the continuity and access mandates for patient-centered care. However, the patient’s experience of care with part-time physicians is relatively unknown, and may be mediated by continuity and access to care outcomes.

OBJECTIVE

We aimed to examine the relationships between a physicians’ clinical full-time equivalent (FTE), continuity of care, access to care, and patient satisfaction with the physician.

DESIGN

We used a multi-level structural equation estimation, with continuity and access modeled as mediators, for a cross-section in 2010.

PARTICIPANTS

The study included family medicine (n = 104) and internal medicine (n = 101) physicians in a multi-specialty group practice, along with their patient satisfaction survey responses (n = 12,688).

MAIN MEASURES

Physician level FTE, continuity of care received by patients, continuity of care provided by physician, and a Press Ganey patient satisfaction with the physician score, on a 0–100 % scale, were measured. Access to care was measured as days to the third next-available appointment.

KEY RESULTS

Physician FTE was directly associated with better continuity of care received (0.172 % per FTE, p < 0.001), better continuity of care provided (0.108 % per FTE, p < 0.001), and better access to care (−0.033 days per FTE, p < 0.01), but worse patient satisfaction scores (−0.080 % per FTE, p = 0.03). The continuity of care provided was a significant mediator (0.016 % per FTE, p < 0.01) of the relationship between FTE and patient satisfaction; but overall, reduced clinical work hours were associated with better patient satisfaction (−0.053 % per FTE, p = 0.03).

CONCLUSIONS

These results suggest that PCPs who choose to work fewer clinical hours may have worse continuity and access, but they may provide a better patient experience. Physician workforce planning should consider these care attributes when considering the role of part-time PCPs in practice redesign efforts and initiatives to meet the demand for primary care services.

Electronic supplementary material

The online version of this article (doi:10.1007/s11606-014-3104-6) contains supplementary material, which is available to authorized users.KEY WORDS: part-time work, continuity of care, access to care, patient satisfaction     

Primary Care Internal Medicine Training and Women's Health

In this study, directors of primary care residency programs were sent a questionnaire that asked for information about their program and examined their perceptions of program curricula and resident mastery of seven preselected topics in women's health. An elective ambulatory gynecology experience was offered in 52% of programs, and 35% of programs had all residents experience such a rotation. All seven selected topics were felt to be important for residents to master, but the prevalence of structured teaching experiences and resident mastery for each topic varied widely. For the majority of programs, domestic violence was not a curricular component. However, 44% of respondents spontaneously commented that they were expanding their curriculum in the area of women's health.     

The Association Between Hospital Readmission and Insurance Provider Among Adults with Asthma

Context. Asthma is ranked as the ninth most common chronic condition in the U.S., and its annual direct costs from hospital services alone are estimated at $3.1 billion. Hospitalization rates due to asthma reveal several disparities and may be attributed to recent changes in the healthcare delivery system, including the penetration of managed care. Objective. To examine the relationship between 7-day hospital readmission and insurance provider among adults with asthma. Design. A retrospective cohort study that included patients aged 18-64 with a principal diagnosis of asthma, who were discharged from acute nonfederal hospitals in New Jersey between 1 January 1993 and 31 December 1996. In the absence of unique patient identifiers, a linkage system was used to match subsequent readmissions for the same patient to the first admission. Main Outcome Measure. Seven-day readmission. Results. Results showed a significantly increased risk of 7-day readmission for managed care patients as compared to indemnity patients (OR = 1.67, 1.10-2.53). Shorter lengths of stay were associated with greater odds of readmission (LOS = 0: OR = 5.17, 2.49-10.75, LOS = 1: OR = 2.30, 1.30-4.07). Conclusions. Managed care patients have shorter lengths of stay as compared to indemnity patients, which leads to an increased risk of returning to the hospital within a short period of time. In trying to provide cost-effective patient care, we may be discharging patients prematurely.     

Determinants of Resident Satisfaction with Patients in Their Continuity Clinic

The purpose of this study was to identify what patient and physician factors influence resident satisfaction with patient encounters in a continuity clinic setting. Resident satisfaction was assessed from postencounter questionnaires completed by 68 internal medicine residents regarding 979 patient encounters. We found that residents were more satisfied with patients diagnosed with general medical problems than with patients diagnosed with pain and psychiatric disorders. First-year residents were less satisfied with patients diagnosed with pain and psychiatric disorders than second- and third-year residents. However, this dissatisfaction with seeing patients with pain or psychiatric disorders lessened as continuity of care was enhanced.     

The Association Between Hospital Readmission and Insurance Provider Among Adults with Asthma

Context. Asthma is ranked as the ninth most common chronic condition in the U.S., and its annual direct costs from hospital services alone are estimated at $3.1 billion. Hospitalization rates due to asthma reveal several disparities and may be attributed to recent changes in the healthcare delivery system, including the penetration of managed care. Objective. To examine the relationship between 7‐day hospital readmission and insurance provider among adults with asthma. Design. A retrospective cohort study that included patients aged 18–64 with a principal diagnosis of asthma, who were discharged from acute nonfederal hospitals in New Jersey between 1 January 1993 and 31 December 1996. In the absence of unique patient identifiers, a linkage system was used to match subsequent readmissions for the same patient to the first admission. Main Outcome Measure. Seven‐day readmission. Results. Results showed a significantly increased risk of 7‐day readmission for managed care patients as compared to indemnity patients (OR = 1.67, 1.10–2.53). Shorter lengths of stay were associated with greater odds of readmission (LOS = 0: OR = 5.17, 2.49–10.75, LOS = 1: OR = 2.30, 1.30–4.07). Conclusions. Managed care patients have shorter lengths of stay as compared to indemnity patients, which leads to an increased risk of returning to the hospital within a short period of time. In trying to provide cost‐effective patient care, we may be discharging patients prematurely.     

Association of Communication Between Hospital-based Physicians and Primary Care Providers with Patient Outcomes

BACKGROUND  Patients admitted to general medicine inpatient services are increasingly cared for by hospital-based physicians rather than their primary care providers (PCPs). This separation of hospital and ambulatory care may result in important care discontinuities after discharge. We sought to determine whether communication between hospital-based physicians and PCPs influences patient outcomes. METHODS  We approached consecutive patients admitted to general medicine services at six US academic centers from July 2001 to June 2003. A random sample of the PCPs for consented patients was contacted 2 weeks after patient discharge and surveyed about communication with the hospital medical team. Responses were linked with the 30-day composite patient outcomes of mortality, hospital readmission, and emergency department (ED) visits obtained through follow-up telephone survey and National Death Index search. We used hierarchical multi-variable logistic regression to model whether communication with the patient’s PCP was associated with the 30-day composite outcome. RESULTS  A total of 1,772 PCPs for 2,336 patients were surveyed with 908 PCPs responses and complete patient follow-up available for 1,078 patients. The PCPs for 834 patients (77%) were aware that their patient had been admitted to the hospital. Of these, direct communication between PCPs and inpatient physicians took place for 194 patients (23%), and a discharge summary was available within 2 weeks of discharge for 347 patients (42%). Within 30 days of discharge, 233 (22%) patients died, were readmitted to the hospital, or visited an ED. In adjusted analyses, no relationship was seen between the composite outcome and direct physician communication (adjusted odds ratio 0.87, 95% confidence interval 0.56 – 1.34), the presence of a discharge summary (0.84, 95% CI 0.57–1.22), or PCP awareness of the index hospitalization (1.08, 95% CI 0.73–1.59). CONCLUSION  Analysis of communication between PCPs and inpatient medical teams revealed much room for improvement. Although communication during handoffs of care is important, we were not able to find a relationship between several aspects of communication and associated adverse clinical outcomes in this multi-center patient sample. This paper was presented at the Society for General Internal Medicine Annual Meeting in April 2006.     

Primary Care Resident Perceived Preparedness to Deliver Cross-cultural Care: An Examination of Training and Specialty Differences

Objective Previous research has shown that resident physicians report differences in training across primary care specialties, although limited data exist on education in delivering cross-cultural care. The goals of this study were to identify factors that relate to primary care residents’ perceived preparedness to provide cross-cultural care and to explore the extent to which these perceptions vary across primary care specialties. Design Cross-sectional, national mail survey of resident physicians in their last year of training. Participants Eleven hundred fifty primary care residents specializing in family medicine (27%), internal medicine (23%), pediatrics (26%), and obstetrics/gynecology (OB/GYN) (24%). Results Male residents as well as those who reported having graduated from U.S. medical schools, access to role models, and a greater cross-cultural case mix during residency felt more prepared to deliver cross-cultural care. Adjusting for these demographic and clinical factors, family practice residents were significantly more likely to feel prepared to deliver cross-cultural care compared to internal medicine, pediatric, and OB/GYN residents. Yet, when the quantity of instruction residents reported receiving to deliver cross-cultural care was added as a predictor, specialty differences became nonsignificant, suggesting that training opportunities better account for the variability in perceived preparedness than specialty. Conclusions Across primary care specialties, residents reported different perceptions of preparedness to deliver cross-cultural care. However, this variation was more strongly related to training factors, such as the amount of instruction physicians received to deliver such care, rather than specialty affiliation. These findings underscore the importance of formal education to enhance residents’ preparedness to provide cross-cultural care.     

Knowledge and Attitudes of Primary Care Physicians Toward Sleep and Sleep Disorders

Purpose: To assess primary care physician (PCP) sleep knowledge and attitudes. Method: A sample of 580 PCPs practicing adult medicine in Northeast Ohio was selected, using a systematic random method (every 10th name on the American Medical Association mailing list). A three-part structured survey consisted of 30 attitude items and 33 multiple-choice test questions assessing knowledge, with some demographic questions. Repeat mailings were sent to nonrespondents 4 to 6 weeks apart from October 1999 through April 2000. Results: 46 surveys were undeliverable and 105 (20%) useable questionnaires were returned. Of respondents, 94% were board certified with 76% certified in more than one area. When asked to rate their knowledge of sleep disorders, none rated themselves as excellent, 10% rated themselves as good, 60% as fair, and 30% as poor. The factors rated highest in influencing current practices regarding sleep and sleep disorders were articles in journals, continuing medical education courses, and discussions with specialists. Knowledge average was 34% (3 to 94%). Though virtually all agreed that prevention counseling should be a part of patient care, fewer agreed that they spend more time counseling patients on the benefits of sleep than of diet or exercise. Conclusions: The majority of PCPs rated their own knowledge of sleep disorders as fair or poor. Knowledge testing and attitude assessment lend credence to these perceptions.     

Co-ordination of Diabetes Care in the Primary and the Secondary Health Care System in Denmark

In Denmark the co-operation between the primary and secondary health care system is organized through referrals. Recommendations for improving interaction between the diabetes team (diabetologists, diabetes nurses, dietitians, chiropodists etc.) at the diabetes clinic, and general practice have been prepared by a working party for the Danish National Board of Health. General recommendations: (a) Appointment of a liaison committee in each county consisting of general practitioners (GPs), diabetologists, administrators, etc. (b) Employment of a GP at the diabetes clinic to take care of improving communication, teaching, research, quality assessment, etc. (c) Referral of all newly diagnosed patients with Type 1 diabetes and younger or complicated patients with Type 2 diabetes to the diabetes clinic. More far-reaching forms of co-operation to be discussed in the liaison committees include: (a) Based upon his own knowledge of where to look for help to solve a specific health problem, the diabetic patient may on his own initiative consult either the diabetes clinic or general practice. (b) Provision of access to consult the diabetes nurse/dietitian at the diabetes clinic for instruction without a formal referral. (c) Patients treated solely in general practice and thus unknown to the diabetes clinic may be referred or reported systematically to the diabetes clinic.     

Factors Affecting Influential Discussions Among Physicians: A Social Network Analysis of a Primary Care Practice

Background Physicians often rely on colleagues for new information and advice about the care of their patients. Objective Evaluate the network of influential discussions among primary care physicians in a hospital-based academic practice. Design Survey of physicians about influential discussions with their colleagues regarding women’s health issues. We used social network analysis to describe the network of discussions and examined factors predictive of a physician’s location in the network. Subjects All 38 primary care physicians in a hospital-based academic practice. Measurements Location of physician within the influential discussion network and relationship with other physicians in the network. Results Of 33 responding physicians (response rate = 87%), the 5 reporting expertise in women’s health were more likely than others to be cited as sources of influential information (odds ratio [OR] 6.81, 95% Bayesian confidence interval [CI] 2.25–23.81). Physicians caring for more women were also more often cited (OR 1.03, 95% CI 1.01–1.05 for a 1 percentage-point increase in the proportion of women patients). Influential discussions were more frequent among physicians practicing in the same clinic within the practice than among those in different clinics (OR 5.03, 95% CI 3.10–8.33) and with physicians having more weekly clinical sessions (OR 1.33, 95% CI 1.15 to 1.54 for each additional session). Conclusions In the primary care practice studied, physicians obtained information from colleagues with greater expertise and experience as well as colleagues who were accessible based on location and schedule. It may be possible to organize practices to promote more rapid dissemination of high-quality evidence-based medicine.     

Care of Older Adults: Role of Primary Care Physicians in the Treatment of Cataracts and Macular Degeneration

This article aims to facilitate optimal management of cataracts and age‐related macular degeneration (AMD) by providing information on indications, risk factors, referral guidelines, and treatments and to describe techniques to maximize quality of life (QOL) for people with irreversible vision loss. A review of PubMed and other online databases was performed for peer‐reviewed English‐language articles from 1980 through August 2012 on visual impairment in elderly adults. Search terms included vision loss, visual impairment, blind, low vision, QOL combined with age‐related, elderly, and aging. Articles were selected that discussed vision loss in elderly adults, effects of vision impairment on QOL, and care strategies to manage vision loss in older adults. The ability of primary care physicians (PCPs) to identify early signs of cataracts and AMD in individuals at risk of vision loss is critical to early diagnosis and management of these common age‐related eye diseases. PCPs can help preserve vision by issuing aptly timed referrals and encouraging behavioral modifications that reduce risk factors. With knowledge of referral guidelines for soliciting low‐vision rehabilitation services, visual aids, and community support resources, PCPs can considerably increase the QOL of individuals with uncorrectable vision loss. By offering appropriately timed referrals, promoting behavioral modifications, and allocating low‐vision care resources, PCPs may play a critical role in preserving visual health and enhancing the QOL for the elderly population.     

A National Survey of Asthma Knowledge and Practices Among Specialists and Primary Care Physicians

Asthma is a chronic disorder that causes significant morbidity and mortality and requires ongoing chronic care. Approximately two‐thirds of people with asthma are receiving care from a primary care clinician, such as an internist, family practitioner, nurse practitioner, or pediatrician. The other one‐third of patients are obtaining treatment and ongoing care from specialists, including allergists or pulmonologists. The outcomes of asthma care are a subject of intense investigation. Many studies focus on pharmacotherapy, allergen control, and asthma education as interventions to reduce the morbidity and costs associated with asthma. Fewer studies have explored the differences in outcomes between asthmatic patients cared for by specialists compared with generalists. Even fewer have explored the practice differences between generalists and specialists that may relate to outcomes of care. With the advent of national asthma guidelines and the high prevalence of asthma seen in primary care settings, it is important to investigate the knowledge, attitudes, and practices of primary care physicians with regard to asthma.     

A National Survey of Asthma Knowledge and Practices Among Specialists and Primary Care Physicians

Asthma is a chronic disorder that causes significant morbidity and mortality and requires ongoing chronic care. Approximately two-thirds of people with asthma are receiving care from a primary care clinician, such as an internist, family practitioner, nurse practitioner, or pediatrician. The other one-third of patients are obtaining treatment and ongoing care from specialists, including allergists or pulmonologists. The outcomes of asthma care are a subject of intense investigation. Many studies focus on pharmacotherapy, allergen control, and asthma education as interventions to reduce the morbidity and costs associated with asthma. Fewer studies have explored the differences in outcomes between asthmatic patients cared for by specialists compared with generalists. Even fewer have explored the practice differences between generalists and specialists that may relate to outcomes of care. With the advent of national asthma guidelines and the high prevalence of asthma seen in primary care settings, it is important to investigate the knowledge, attitudes, and practices of primary care physicians with regard to asthma.     

An Essential Guide for Managing Post-Liver Transplant Patients: What Primary Care Physicians Should Know

With long-term survival after liver transplantation becoming the rule, care for medical problems arising over time in liver-transplanted patients gained increasing importance. The most common causes of death occurring more than 1 year after liver transplantation are unrelated to liver diseases and facilitated by immunosuppressive treatments; examples are malignancies, renal failure, and cardiovascular, metabolic, and infectious diseases. Recipients receive life-long follow-up care at transplant centers, however, the increasing number of liver-transplanted patients is saturating the health care supply that transplant centers have to offer. Primary care physicians are increasingly exposed to liver-transplanted patients, even in the early periods after transplant, and an understanding of the most common risks and complications faced by these patients would enhance their care. This article reviews the long-term care of liver transplant recipients, emphasizing the key internal medicine-related issues that should be known by primary care physicians. A specific section is devoted to implementing strategies to involve these physicians in the long-term follow-up of liver-transplanted patients in close collaboration with transplant hepatologists.