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.     

Preventive cancer screening practices in HIV-positive patients

As patients with HIV age, they are at risk of developing non-AIDS defining malignancies. We performed a questionnaire study to evaluate colorectal and breast cancer screening among HIV-positive and HIV-negative patients seeking care from either an integrated (HIV/primary care), nonintegrated (specialized HIV), or general internal medicine clinic between August 2010 and July 2011. We performed a logistic regression to determine the odds of cancer screening. A total of 813 surveys were collected, and 762 were included in the analysis. As much as 401 were from HIV-positive patients. Patients with HIV were less likely to be current with their colorectal cancer screening (CRCS) (54.4% versus 65.0%, p=0.009); mammography rates were 24.3% versus 62.3% if done during the past year (p<0.001), and 42.0% versus 86.7% if done during the past 5 years (p<0.001). In adjusted models, the odds of colorectal cancer screening in HIV-positive patients compared to negative controls was not statistically significant (OR 0.8; 95% CI 0.5–1.3); however, HIV-positive women remained significantly less likely to be current with breast cancer screening (BCS) whether their mammogram was completed within 1 year (OR 0.1, 95% CI 0.1–0.2) or within 5 years (OR 0.1, 95% CI 0.0–0.2). Integrated care was not associated with improved screening; however, having frequent visits to a primary care physician (PCP) increased the likelihood of getting screened. BCS was lower in HIV-positive compared to HIV-negative women. Frequent visits to a PCPs improved cancer screening.     

Unhealthy Drinking Patterns and Receipt of Preventive Medical Services by Older Adults

Background  Preventive service use among older adults is suboptimal. Unhealthy drinking may constitute a risk factor for failure to receive these services. Objectives  To determine the relationship between unhealthy drinking and receipt of recommended preventive services among elderly Medicare beneficiaries, applying the framework of current alcohol consumption guidelines. Design/Methods  The data source is the nationally representative 2003 Medicare Current Beneficiary Survey. The sample included community-dwelling, fee-for-service Medicare beneficiaries 65 years and older (N = 10,523). Based on self-reported drinking, respondents were categorized as nondrinkers, within-guidelines drinkers, exceeding monthly but not daily limits, or heavy episodic drinkers. Using survey and claims data, influenza vaccination, pneumonia vaccination, glaucoma screening, and mammogram receipt were determined. Bivariate and logistic regression analyses were conducted. Results  Overall, 70.3% received flu vaccination and 49% received glaucoma screening during the year, 66.8% received pneumonia vaccination, and 56.2% of women received a mammogram over 2 years. In logistic regression, heavy episodic drinking was associated with lower likelihood of service receipt compared to drinking within guidelines: flu vaccination (OR 0.75, CI 0.59–0.96), glaucoma screening (OR 0.74, CI 0.58–0.95), and pneumonia vaccination (OR 0.75, CI 0.59–0.96). Nondrinkers when compared with those reporting drinking within guidelines were less likely to receive a mammogram (OR 0.83, CI 0.69–1.00). Conclusions  Heavy episodic drinking is associated with lower likelihood of receiving several preventive services. Practitioners should be encouraged to screen all elders regarding alcohol intake and in addition to appropriate intervention, consider elders reporting heavy episodic drinking at higher risk for non-receipt of preventive services.     

Variation in Internal Medicine Residency Clinic Practices: Assessing Practice Environments and Quality of Care

Background  Few studies have systematically and rigorously examined the quality of care provided in educational practice sites. Objective  The objectives of this study were to (1) describe the patient population cared for by trainees in internal medicine residency clinics; (2) assess the quality of preventive cardiology care provided to these patients; (3) characterize the practice-based systems that currently exist in internal medicine residency clinics; and (4) examine the relationships between quality, practice-based systems, and features of the program: size, type of program, and presence of an electronic medical record. Design  This is a cross-sectional observational study. Setting  This study was conducted in 15 Internal Medicine residency programs (23 sites) throughout the USA. Participants  The participants included site champions at residency programs and 709 residents. Measurements  Abstracted charts provided data about patient demographics, coronary heart disease risk factors, processes of care, and clinical outcomes. Patients completed surveys regarding satisfaction. Site teams completed a practice systems survey. Results  Chart abstraction of 4,783 patients showed substantial variability across sites. On average, patients had between 3 and 4 of the 9 potential risk factors for coronary heart disease, and approximately 21% had at least 1 important barrier of care. Patients received an average of 57% (range, 30–77%) of the appropriate interventions. Reported satisfaction with care was high. Sites with an electronic medical record showed better overall information management (81% vs 27%) and better modes of communication (79% vs 43%). Conclusions  This study has provided insight into the current state of practice in residency sites including aspects of the practice environment and quality of preventive cardiology care delivered. Substantial heterogeneity among the training sites exists. Continuous measurement of the quality of care provided and a better understanding of the training environment in which this care is delivered are important goals for delivering high quality patient care.     

Primary care and receipt of preventive services

OBJECTIVE: To examine whether health insurance, a regular place of care, and optimal primary care are independently associated with receiving preventive care services. DESIGN: A cross-sectional telephone survey. SETTING: Population based. PARTICIPANTS: Probability sample of 3,846 English-speaking and Spanish-speaking women between the ages of 18 and 64 in urban California. INTERVENTIONS: Women were asked about their demographic characteristics, financial status, health insurance status, need for ongoing care, regular place of care, and receipt of blood pressure screening, clinical breast examinations, mammograms, and Pap smears. Women who reported a regular place of care were asked about four components of primary care: availability, continuity, comprehensiveness, and communication. MEASUREMENTS AND MAIN RESULTS: In multivariate analyses that controlled for differences in demographics, financial status, and need for ongoing care, having a regular place of care was the most important factor associated with receiving preventive care services (p<.0001). Having health insurance (p<.001) and receiving optimal primary care from the regular place of care (p<.01) further significantly increased the likelihood of receiving preventive care services. CONCLUSION: A regular source of care is the single most important factor associated with the receipt of preventive services, but optimal primary care from a regular place increases the likelihood that women will receive preventive care. Supported by Robert Wood Johnson Foundation grant 22907 and Agency for Health Care Policy Research (AHCPR) grant HSO7373. Dr. Bindman and Dr. Grumbach are Robert Wood Johnson Foundation Generalist Physician Faculty Scholars.     

Trends in Follow-up and Preventive Care for Colorectal Cancer Survivors

Background As cancer patients transition from treatment to survivorship, the responsibility of primary care providers (PCPs) versus oncology specialists is unclear. Objectives To explore (1) physician types (PCPs versus oncology specialists) survivors visit during survivorship year 1, (2) preventive care received, (3) how preventive care receipt relates to physician types visited, and (4) trends in physician types visited and preventive care received over time. Design Retrospective cross-sectional study of 5 cohorts of cancer survivors in survivorship year 1. Subjects Twenty thousand sixty-eight survivors diagnosed with stage 1–3 colorectal cancer between 1997 and 2001. Measurements Using the SEER-Medicare database, we assessed the mean number of visits to different physician types, the percentage of survivors receiving preventive services, how receipt of preventive services related to physician types visited, and trends over time in physician visits and preventive care. Results There was a trend over time of increased visits to all physician types, which was statistically significant for oncology specialists and other physicians (p < .001) but not PCPs. The percentage of survivors receiving preventive services remained relatively stable across the 5 cohorts, except for an increase in bone densitometry (p < .05). Survivors who visited both a PCP and oncology specialist were most likely to receive each preventive care service (p < .05). Conclusions Oncology specialist follow-up in survivorship year 1 is intensifying over time. Survivors not being followed-up by both PCPs and oncology specialists were less likely to receive preventive care. Clarifying the roles of PCPs and oncology specialists during follow-up can improve the quality of care for survivors. Presented at the 2007 Society for General Internal Medicine Annual Meeting.     

Patterns of HIV and mental health service integration in New York State

The Affordable Care Act (ACA) creates incentives to coordinate primary care, mental health (MH) care, and addiction services. Integration of clinical HIV and MH services has been shown to improve quality of life and physical and MH of people living with HIV/AIDS. However, few studies have investigated the practice of service integration systematically. We examined the practice patterns of 515 direct service providers in New York State who received training about HIV MH between May 2010 and July 2012. We sought to identify provider and treatment setting characteristics associated with an integrated spectrum of care. Using factor analysis and linear modeling, we found that patterns of service integration varied by type of health-care setting, service setting location, providers' HIV caseload, and the discipline of the provider describing the direct services. Understanding the existing capacities of clinicians providing care in a variety of settings throughout New York will help to guide staffing and linkage to enhance HIV MH service integration as significant shifts in the organization of health care occur.     

Screening and treatment of diabetic nephropathy by primary care physicians

OBJECTIVE: To describe the practices of Indiana primary care physicians related to diabetic nephropathy screening and management. DESIGN: Cross-sectional, observational. SETTING: The state of Indiana. PARTICIPANTS: Active primary care physicians (defined as general internists, family practitioners, and general practitioners) in Indiana who provided care for diabetic patients at the time of the survey (n = 1,018) MEASUREMENTS AND MAIN RESULTS: Practice patterns relevant to microalbuminuria and overt albuminuria screening and management were assessed along two dimensions: the percentage of patients to whom the practices were applied and the frequency with which the practices were performed. Of 1,141 physicians who responded to the survey, 1,018 were eligible for analysis. Eighty-six percent of physicians reported screening more than half of their patients with type 1 diabetes for overt albuminuria, as did 82% of physicians for their patients with type 2 diabetes. Only 17% of physicians indicated performing microalbuminuria testing on more than half of their type 1 patients. Angiotensin-converting enzyme inhibitor agents were used frequently to treat abnormal urinary albumin excretion when hypertension was present, but less often when hypertension was absent. Physician specialty, year of graduation from medical school, practice location, and familiarity with the results of the Diabetes Control and Complications Trial were significant predictors of screening and treatment practice patterns. CONCLUSIONS: Primary care physicians report practices that allow them to detect overt albuminuria but not microalbuminuria. Angiotensin-converting enzyme inhibitors are frequently used by physicians who test for microalbuminuria, but efforts to increase the detection of early renal damage are needed so that these agents and other therapeutic strategies may be employed at the earliest opportunity.     

Implementing Routine Cognitive Screening of Older Adults in Primary Care: Process and Impact on Physician Behavior

Background Early detection of cognitive impairment is a goal of high-quality geriatric medical care, but new approaches are needed to reduce rates of missed cases. Objective To evaluate whether adding routine cognitive screening to primary care visits for older adults increases rates of dementia diagnosis, specialist referral, or prescribing of antidementia medications. Setting Four primary care clinics in a university-affiliated primary care network. Design A quality improvement screening project and quasiexperimental comparison of 2 intervention clinics and 2 control clinics. The Mini-Cog was administered by medical assistants to intervention clinic patients aged 65+ years. Rates of dementia diagnoses, referrals, and medication prescribing were tracked over time using computerized administrative data. Results Twenty-six medical assistants successfully screened 70% (n = 524) of all eligible patients who made at least 1 clinic visit during the intervention period; 18% screened positive. There were no complaints about workflow interruption. Relative to baseline rates and control clinics, Mini-Cog screening was associated with increased dementia diagnoses, specialist referrals, and prescribing of cognitive enhancing medications. Patients without previous dementia indicators who had a positive Mini-Cog were more likely than all other patients to receive a new dementia diagnosis, specialty referral, or cognitive enhancing medication. However, relevant physician action occurred in only 17% of screen-positive patients. Responses were most related to the lowest Mini-Cog score level (0/5) and advanced age. Conclusion Mini-Cog screening by office staff is feasible in primary care practice and has measurable effects on physician behavior. However, new physician action relevant to dementia was likely to occur only when impairment was severe, and additional efforts are needed to help primary care physicians follow up appropriately on information suggesting cognitive impairment in older patients. An erratum to this article can be found at     

Over and under-utilization of cyclooxygenase-2 selective inhibitors by primary care physicians and specialists

OBJECTIVES: To compare prescribing trends and appropriateness of use of traditional and cyclooxygenase-2 selective (COX-2) nonsteroidal anti-inflammatory drugs (NSAIDs) by primary care physicians (PCPs) and specialists. DESIGN: Retrospective cohort study. PATIENTS: One thousand five hundred and seventy-six adult patients continuously enrolled for at least 1 year with an independent practice association of a University-associated managed care plan who were started on a traditional NSAID or a COX-2 inhibitor from 1999 to 2002 and received at least 3 separate medication fills. MEASUREMENTS: Physician specialty was identified from office visits. Appropriateness of utilization was based on gastrointestinal risk characteristics. RESULTS: Primary care patients were younger and less likely to have comorbid conditions. Despite similar GI risk, COX-2 use among patients seen by PCPs was half that of patients seen by specialists (21% vs 44%, P<.001). While PCPs overused cyclooxygenase-2-specific inhibitors (COX-2s) less often than specialists (19% vs 41%, P<.001), they also tended to underuse COX-2s in patients who were at increased GI risk (46% vs 32%, P=.063). This represents a 3-fold and 8-fold difference in overuse versus underuse for PCPs and specialists, respectively. CONCLUSIONS: Using COX-2s as a model for physician adoption of new therapeutic agents, specialists were more likely to use these new medications for patients likely to benefit but were also significantly more likely to use them for patients without a clear indication. This study demonstrates the tension between appropriate adoption of innovative therapies for those individuals who would benefit from their use and those individuals who would receive no added clinical benefit but would incur added cost and be placed at increased risk.     

Physician Attitudes Concerning Anticoagulation Services in the Long-Term Care Setting

Objectives: There is little experience in the use of specialized anticoagulation services in the long-term care setting. Even less is known about physician attitudes regarding these services. To examine this issue, we surveyed physicians caring for nursing home residents in a sample of long-term care facilities located in Connecticut. Methods: We surveyed physicians providing care to nursing home residents of a convenience sample of 21 Connecticut nursing homes. (These facilities had participated in a quality assessment and improvement project on preventing strokes in nursing home residents with atrial fibrillation.) Physicians were requested to complete a structured questionnaire about the challenges to managing nursing home residents on warfarin therapy and preferences concerning the use of an anticoagulation service to manage warfarin therapy in this setting. Results: A total of 245 physicians were asked to participate in the survey, and 114 (47%) responded between November 5, 1999 and January 14, 2000. Of the 114 physicians who returned the survey, 91 reported that they currently cared for residents in long-term care facilities and thus completed the questionnaire. The majority of respondents agreed or strongly agreed that an anticoagulation service would reduce the workload on physicians, increase the costs of care for nursing home residents on warfarin, and increase the percent of time that nursing home residents on warfarin are maintained in the target therapeutic range. Most physicians disagreed or strongly disagreed with statements suggesting an anticoagulation service would decrease the costs of care for nursing home residents on warfarin, reduce the liability of the prescribing physician, interfere with their ability to care for patients on warfarin therapy, and reduce the risk of warfarin-related bleeding. Forty-five percent of respondents agreed with a statement that an anticoagulation service would intrude on physician decision-making. Only about half (53%) of the respondents indicated that they would or might utilize an anticoagulation service for managing their long-term care patients on warfarin. Conclusions: Use of a specialized anticoagulation service to manage warfarin therapy is a systems-level approach with the potential to improve the effectiveness and safety of this treatment. Physician skepticism regarding the usefulness of anticoagulation services will only be overcome by subjecting this approach to rigorous evaluation and by assuring physicians of their ongoing involvement in decision-making regarding warfarin therapy in their patients.     

Prediction of a 10-year risk of type 2 diabetes mellitus in the Turkish population: A cross-sectional study

According to the International Diabetes Federation, Turkey will be among the top 10 countries in the world with the highest prevalence of diabetes mellitus (DM) by 2045, with a speculated number of cases of 10.4 million.This study aimed to predict the 10-year risk of type 2 DM in a Turkish population, assess potential factors of the 10-year risk of DM, and assess the outcomes of Turkey''s 2015 to 2020 program for DM.Individuals aged 20–64 years were categorized and stratified according to age (in ranges of 5 years), sex, and populations of family medicine centers to reflect the whole population. The Finnish Diabetes Risk Score, sociodemographic characteristics, body fat, muscle, bone ratio, blood pressure, and waist-to-height ratio were evaluated.We found that 9.5% (n = 71) of the population aged 20 to 64 years will have DM within the next 10 years. Low levels of education (odds ratio [OR]: 2.054; 95% confidence interval [CI]: 1.011–4.174), smoking cessation (OR: 2.636; 95% CI: 1.260–5.513), a waist-to-height ratio >0.5 (OR: 6.885; 95% CI: 2.301–20.602), body fat percentage (OR: 1.187; 95% CI: 1.130–1.247), high systolic blood pressure (OR: 1.025; 95% CI: 1.009–1.041), and alcohol consumption (beta-estimation: −0.690; OR: 0.501; 95% CI: 0.275–0.914) affect the 10-year risk of type 2 DM.Individuals at risk for DM can be easily identified using risk assessment tools in primary care; however, there is no active screening program in the healthcare system, and only proposals exist. In addition to screening, preventive measures should focus on raising awareness of DM, reducing body fat percentage and systolic blood pressure, and decreasing the waist-to-height ratio to <0.5.     

Prevalence of basic information technology use by U.S. physicians

BACKGROUND: Information technology (IT) has been advocated as an important means to improve the practice of clinical medicine. OBJECTIVES: To determine current prevalence of non-electronic health record (EHR) IT use by a national sample of U.S. physicians, and to identify associated physician, practice, and patient panel characteristics. DESIGN, SETTING, AND PARTICIPANTS: Survey conducted in early 2004 of 1,662 U.S. physicians engaged in direct patient care selected from 3 primary care specialties (family practice, internal medicine, pediatrics) and 3 nonprimary care specialties (anesthesiology, general surgery, cardiology). MEASUREMENTS: Self-reported frequency of e-mail communication with patients or other clinicians, online access to continuing medical education or professional journals, and use of any computerized decision support (CDS) during clinical care. Survey results were weighted by specialty and linked via practice zip codes to measures of area income and urbanization. RESULTS: Response rate was 52.5%. Respondents spent 49 (+/-19) (mean [+/-standard deviation]) hours per week in direct patient care and graduated from medical school 23 (+/-11) years earlier. "Frequent" use was highest for CDS (40.8%) and online professional journal access (39.0%), and lowest for e-mail communication with patients (3.4%). Ten percent of physicians never used any of the 5 IT tools. In separate logistic regression analyses predicting usage of each of the 5 IT tools, the strongest associations with IT use were primary care practice (adjusted odds ratios [aORs] ranging from 1.34 to 2.26) and academic practice setting (aORs 2.17 to 5.41). Years since medical school graduation (aOR 0.85 to 0.87 for every 5 years after graduation) and solo/2-person practice setting (aORs 0.21 to 0.55) were negatively associated with IT use. Practice location and patient panel characteristics were not independently associated with IT use. CONCLUSIONS: In early 2004, the majority of physicians did not regularly use basic, inexpensive, and widely available IT tools in clinical practice. Efforts to increase the use of IT in medicine should focus on practice-level barriers to adoption.     

A Direct Comparison of the Clinical Practice Patterns of Advanced Practice Providers and Doctors

BackgroundRising health care costs, physician shortages, and an aging patient population have increased the demand and utilization of advanced practice providers (APPs). Despite their expanding role in care delivery, little research has evaluated the care delivered by APPs compared with physicians.MethodsWe used clinical patient simulations to measure and compare the clinical care offered by APPs and physicians, collecting data from 4 distinct health care systems/hospitals in the United States between 2013 and 2017. Specialties ranged from primary care to hospital medicine and oncology. Primary study outcomes were to 1) measure any differences in practice patterns between APPs and physicians, and 2) determine whether the use of serial measurement and feedback could mitigate any such differences.ResultsAt baseline, we found no major differences in overall performance of APPs compared with physicians (P = .337). APPs performed 3.2% better in history taking (P = .013) and made 10.5% fewer unnecessary referrals (P = .025), whereas physicians ordered 17.6% fewer low-value tests per case (P = .042). Regardless of specialty or site, after 4 rounds of serial measurement and provider-specific feedback, APPs and physicians had similar increases in average overall scores—7.4% and 7.6%, respectively (P < .001 for both). Not only did both groups improve, but practice differences between the groups disappeared, leading to a 9.1% decrease in overall practice variation.ConclusionsWe found only modest differences in quality of care provided by APPs and physicians. Importantly, both groups improved their performance with serial measurement and feedback so that after 4 rounds, the original differences were mitigated entirely and overall variation significantly reduced. Our data suggest that APPs can provide high quality care in multiple clinical settings.     

Factors associated with the frequency of house calls by primary care physicians

Objective:To evaluate factors associated with the frequency of house calls by primary care physicians. Design:A cross-sectional design with a self-administered mailed survey. Setting/participants:751 primary care physicians who care for Medicaid patients in Virginia. Results:Among 389 physician respondents (52%), regular house callers (n=216) were compared with occasional house callers (n=162). Among physician characteristics, specialty and practice duration were associated with house call frequency. Regular house callers also more often cited chronic illness (67% vs. 20%, p<0.01) and terminal illness (67% vs. 40%, p<0.01) as indications for house calls, compared with occasional house callers. Use of visiting nurses to substitute for physician house calls was less often considered appropriate by frequent house callers (7% vs. 24%, p<0.01), and regular house callers were less likely to report being “too busy” to make house calls (71% vs. 29%, p<0.01). Multivariate analysis confirmed the association of these attitudes with house call frequency. Conclusion:These data suggest that specific attitudes among primary care physicians are associated with house call frequency. Presented in part at the annual meeting of the Society of General Internal Medicine, May 2–4, 1990, Arlington, Virginia. Supported in part by a grant from Virgina Commonwealth University.     

Physician specialization and antiretroviral therapy for HIV

BACKGROUND: Since the introduction of the first protease inhibitor in January 1996, there has been a dramatic change in the treatment of persons infected with HIV. The changing nature of HIV care has important implications for the types of physicians that can best care for patients with HIV infection. OBJECTIVE: To assess the association of specialty training and experience in the care of HIV disease with the adoption and use of highly active antiretroviral (ARV) therapy (HAART). DESIGN: Observational cohort study of patients under care for HIV infection and their physicians. PATIENTS AND SETTING: This analysis used data collected from a national probability sample of noninstitutionalized persons with HIV infection participating in the HIV Costs and Service Utilization Study and their primary physicians. We analyzed 1,820 patients being cared for by 374 physicians. MEASUREMENTS: Rates of HAART use at 12 months and 18 months after the approval of the first protease inhibitor. RESULTS: Forty percent of the physicians were formally trained in infectious diseases (ID), 38% were general medicine physicians with self-reported expertise in the care of HIV, and 22% were general medicine physicians without self-reported expertise in the care of HIV. The majority of physicians (69%) reported a current HIV caseload of 50 patients or more. In multivariable models controlling for patient characteristics, there were no differences between generalist experts and ID physicians in rates of HAART use in December 1996. When compared to ID physicians, however, patients being treated by non-expert general medicine physicians were less likely to be on HAART (odds ratio [OR], 0.32; 95% confidence interval [95% CI], 0.17 to 0.61). Patients being treated by low-volume physicians were also much less likely to be on HAART therapy than those treated by high-volume physicians (OR, 0.26; 95% CI, 0.14 to 0.48). These findings were attenuated by June 1997, suggesting that over time, the broader physician community successfully adopted HAART therapy. This finding is consistent with prior research on the diffusion of innovations. CONCLUSIONS: Similar proportions of patients treated by expert generalists and ID specialists were on appropriate HAART therapy by December 1996 and July 1997. Patients treated by non-expert generalists, most of whom were the lowest-volume physicians, were much less likely to be on appropriate ARV therapy in the earlier time period. Our findings demonstrate that expert generalists who develop specialized expertise are able to provide care of quality comparable to that of specialists.     

Perceived Discrimination in Health Care and Use of Preventive Health Services

Objective  To examine the relationship between perceived discrimination and preventive health care utilization. Design and Participants  Cross-sectional analysis using the 2004 Behavioral Risk Factor Surveillance System “Reactions to Race” module (N = 28,839). Measurements  Outcomes were self-reported utilization of seven preventive health services. Predictors included perceived negative and positive racial discrimination (vs. none) while seeking health care in the past year. Multivariable models adjusted for additional patient characteristics. Main Results  In unadjusted models, negative discrimination was significantly associated with less utilization of mammogram, pap test, PSA test, blood stool test, and sigmoidoscopy/colonoscopy (ORs = 0.53–0.73, p < .05), but not flu or pneumococcal vaccines (ORs = 0.76 and 0.84). Positive discrimination was significantly associated with more utilization of all services (ORs = 1.29–1.58, p < .05) except pap test (OR = 0.94). In adjusted models, neither negative nor positive discrimination was predictive of utilization, except for PSA test (positive discrimination OR = 1.33, p < .05). Conclusions  Perceived racial discrimination in health care does not independently predict preventive health care utilization.     

Statewide Evaluation of Measuring Physician Delivery of Self-Management Support in Chronic Disease Care

BACKGROUND  Self-management support is an important component of improving chronic care delivery. OBJECTIVE  To validate a new measure of self-management support and to characterize performance, including comparisons across chronic conditions. DESIGN, SETTING, PARTICIPANTS  We incorporated a new question module for self-management support within an existing annual statewide patient survey process in 2007. MEASUREMENTS  The survey identified 80,597 patients with a chronic illness on whom the new measure could be evaluated and compared with patients’ experiences on four existing measures (quality of clinical interactions, coordination of care, organizational access, and office staff). We calculated Spearman correlation coefficients for self-management support scores for individual chronic conditions within each medical group. We fit multivariable logistic regression models to identify predictors of more favorable performance on self-management support. RESULTS  Composite scores of patient care experiences, including quality of clinical interactions (89.2), coordination of care (77.6), organizational access (76.3), and office staff (85.8) were higher than for the self-management support composite score (69.9). Self-management support scores were highest for patients with cancer (73.0) and lowest for patients with hypertension (67.5). The minimum sample size required for medical groups to provide a reliable estimate of self-management support was 199. There was no consistent correlation between self-management support scores for individual chronic conditions within medical groups. Increased involvement of additional members of the healthcare team was associated with higher self-management support scores across all chronic conditions. CONCLUSION  Measurement of self-management support is feasible and can identify gaps in care not currently included in standard measures of patient care experiences.