Emotions and medicine. What do patients expect from their physicians?

Skin cancer control in the primary care setting: are we making any progress?

This paper deals with the some of the important variable factors relating to health care in Saudi Arabia, with special emphasis on primary health. Other aspects considered are the financial influen...

BACKGROUND: While past studies suggest that primary care physicians underdiagnose and undertreat depression, little is known about recent national patterns of depression treatment. METHOD: Using the 1995 and 1996 National Ambulatory Medical Care Surveys, we analyzed 1322 primary care office visits by patients reported to have depression. Rates of psychotherapy/mental health counseling, antidepressant use, and benzodiazepine use were assessed. Independent predictors of depression therapy were examined using multiple logistic regression. Where instructive, we compared the practices of primary care physicians with those of psychiatrists (2418 depression visits). RESULTS: Primary care physicians reported depression in 7.8% of their office visits. For these depression visits, antidepressants (42%) were the most common form of treatment, followed by psychotherapy/mental health counseling (28%) and benzodiazepines (21%). Among specific antidepressants, selective serotonin reuptake inhibitors were most often prescribed by primary care physicians (26% of depression visits). Rates of antidepressant and benzodiazepine use varied significantly by primary care specialty. In addition, geographic region and health insurance status influenced the likelihood of receiving benzodiazepines. In their depression visits, psychiatrists reported psychotherapy/mental health counseling (88%) most frequently, followed by antidepressants (64%) and benzodiazepines (25%). CONCLUSION: The predominant use of selective serotonin reuptake inhibitors suggests that primary care physicians have begun to adopt new therapeutic strategies for depression. The modest rate of antidepressant therapy for a clinical population specifically identified by primary care physicians as having depression may indicate undertreatment of depression in primary care settings. Furthermore, high rates of benzodiazepine use are inconsistent with treatment guidelines, and variations in treatment patterns suggest that nonclinical factors influence depression management.

Exploring the Potential Causes of the Emergence of Hospitalists: Chicken vs. Egg

In North Carolina, ∼5% or 57 000 children enrolled in Medicaid have complex medical conditions and account for >50% of the Medicaid dollars spent each year on the medical care of children. In 2012, Community Care of North Carolina (CCNC) received a Center for Medicare and Medicaid Innovations grant to establish the North Carolina Child Health Accountable Care Collaborative (CHACC) to address the health care needs of these children. Care coordination is an integral part of health reform activities, including many Medicare programs. CHACC appears to use a unique approach of targeting higher-cost pediatric Medicaid patients and placing specialty care managers in tertiary children's services.1,2 CCNC serves North Carolina Medicaid beneficiaries through a statewide, community-based public–private partnership, providing care through medical homes using population management approaches to improve care and contain costs.3 CHACC encourages medical and other health professionals to improve quality and cost-effectiveness of care for children on Medicaid with complex medical conditions. A primary goal of CHACC is to ensure that every child with a complex illness has a medical home in the community where he or she lives and receives coordinated primary and subspecialty care to reduce care fragmentation and cost. One target is reduction of unnecessary emergency department visits and hospitalizations. Although hospital revenues will be affected, hospitals will be better positioned to compete in the value-based care environment.4 CHACC patients are all North Carolina Medicaid beneficiaries enrolled in CCNC for care, allowing seamless identification and clinical information exchange by CHACC staff who are CCNC employees.Historically, CCNC has focused on primary care; however, CHACC bridges subspecialty and hospital-based care at 13 North Carolina hospitals with tertiary children's services with embedded care coordinators. The care coordinators are nurses or social workers with pediatric clinical experience. Their activities include completion of a comprehensive assessment of patient and family needs, care plan development, referrals to community services, patient and caretaker education, and collaboration with providers and caregivers to facilitate transitions in care. They provide a "warm handoff" to the community-based CCNC care coordinators in primary care practices and serve as dedicated links between the subspecialist team and primary care professionals. Care plans for these children are posted on a secure CCNC web-based provider portal, giving primary care professionals a centralized site to review and download care plans and to communicate with the community-based and tertiary care coordinators and subspecialists. The care plans have been well received by the community-based physicians caring for these children, reducing the communication burden of caretakers as intermediaries. A family satisfaction survey is being used to gain insight into caretaker perspectives. As one of the participating pediatric surgeons said, "This [CHACC program] is what I have been waiting for. With the care plan, I had everything I needed to care for the child in front of me. It is better than our brand new EHR!"Identifying the target population for CHACC enrollment is a continuing challenge. Nationally accepted tools for predictive models to identify children with complex medical conditions whose care may be "impactable" (quality improvement and cost reduction) have not been developed. To address this gap, North Carolina Medicaid claim data were used to help identify patient populations who may benefit from the program. In parallel, claim data for CHACC-enrolled children are being collected to determine impact on Medicaid costs, initially comparing CHACC patients with historical groups of similar patients. Advanced analytics are being developed to create predictive models to identify "impactable" patients early in their course, providing the opportunity for care managers to improve quality of care, comanagement, and cost reduction. To date, >1500 patients have been enrolled in CHACC in the first 6 months of the program. Collaborative learning is a key part of CHACC. At the 5 academic centers, work is under way to develop approaches for transitioning care to medical homes in the community using comanagement partnerships with subspecialists. For example, in a 29-county area of eastern North Carolina, the Department of Pediatrics at East Carolina University established the Center for Children with Complex and Chronic Conditions (C5) in 2008. From 2008 to 2010, C5 enrolled 234 children with complex conditions (eg, tracheostomies, gastrostomy tubes, ventilators, feeding pumps, cerebral palsy, intellectual disabilities, complex genetic syndromes) and began coordinating inpatient and outpatient care of these children. CHACC is aiding C5 with additional care managers and new communication links with primary care physicians. So far, C5 staff have documented a 20% reduction in average inpatient length of stay for ventilator-dependent patients, a 36% reduction in readmissions during the first month after discharge, a 26% reduction in readmissions during the first year after initial discharge, a 55% reduction in overall rehospitalizations, and an 11% reduction in emergency department visits. The calculated savings total for 2008 to 2010 is >$6 million.5 To continue this program, care coordination is necessary to support these children in the community. Also, residents, primary care physicians, and parents need more education about the patient's care.To address issues of access to subspecialists across North Carolina, CHACC is developing concise guidelines to aid primary care providers in the care of children with common pediatric conditions often referred prematurely or unnecessarily to pediatric subspecialists. CHACC guidelines are developed in joint day-long work groups of pediatric subspecialists from North Carolina academic medical centers and community primary care physicians. The work group reviews evidence-based data, published guidelines, and, where conclusive data are not available, consensus of subspecialists and primary care physicians on guideline content. A subgroup writes a draft guideline, sharing it for review with subspecialists and generalists across the state. The final guideline is published on the CCNC Web site (https://www.communitycarenc.org/emerging-initiatives/child-health-accountable-care-collaborative/chacc-gi/). Guidelines include consensus recommendations for appropriate primary care clinical evaluation, including laboratory, imaging, management guidance, "red flag" guidelines for immediate referral, and patient and family educational material. Final guidelines include endorsement from the subspecialty groups at all 5 North Carolina academic medical centers. The CHACC steering committee works with the North Carolina chapter of the American Academy of Pediatrics and the CCNC networks across the state to educate primary care health professionals about the guidelines and to encourage their use. Guidelines for constipation, gastroesophageal reflux, and chronic abdominal pain are available, and a guideline for headaches is in draft review.Informal feedback from primary care providers describes the guidelines as easy to download in a busy primary care practice and useful for patient care and family education. It is expected that this tool will aid in convincing families and patients to continue care in the primary care setting unless patients manifest "red flag" symptoms or meet referral guidelines. More formal evaluation of the impact of these guidelines on subspecialty access is under way.CHACC appears to create a unique, care management–based, statewide engagement of pediatric subspecialists and general pediatricians and primary care providers for developing comanagement protocols for children with complex conditions and promoting coordinated, efficient, high-quality, and cost-effective care. As medical providers in North Carolina engage in payment reform transition, including risk-based contracting, CHACC provides a platform to evaluate high-cost medical care for children. We anticipate that the cost savings from CHACC will be useful in justifying continuation of the program after completion of the grant-funded work and will be a stepping stone to value-based care for children in North Carolina Medicaid and adults with high-cost chronic illness moving between levels of care.Our work leads us to call for more development of tools for predictive analysis and risk adjustment for medically complex children, and we are pleased to see others working in this area.6 More work is needed in subspecialty referral management using tools such as the CHACC guidelines. We believe the medically complex child and the structure of the health care delivery system for these children reinforces the old saying, "Children are not just little adults."7Elizabeth Cuervo Tilson, MD, carried out the initial review of the manuscript and provided revisions to the original document.

Family Physicians Sue to Shine Light on RUC Deliberations, Claim Specialists Skew Reimbursement Against Primary Care

Major depressive disorder affects one in five adults in the United States. While practice guidelines recommend universal screening for depression in primary care settings, clinical outcomes suffer in the absence of optimal models to manage those who screen positive for depression. The current practice of employing additional mental health professionals perpetuates the assumption that primary care providers (PCP) cannot effectively manage depression, which is not feasible, due to the added costs and shortage of mental health professionals. We have extended our previous work, which demonstrated similar treatment outcomes for depression in primary care and psychiatric settings, using measurement-based care (MBC) by developing a model, called Primary Care First (PCP-First), that empowers PCPs to effectively manage depression in their patients. This model incorporates health information technology tools, through an electronic health records (EHR) integrated web-application and facilitates the following five components: (1) Screening (2) diagnosis (3) treatment selection (4) treatment implementation and (5) treatment revision. We have implemented this model as part of a quality improvement project, called VitalSign6, and will measure its success using the Reach, Efficacy, Adoption, Implementation, and Maintenance (RE-AIM) framework. In this report, we provide the background and rationale of the PCP-First model and the operationalization of VitalSign6 project.

Experts Outline Costs, Barriers To High-Quality Depression Treatment

The aims of this study were a) to assess the ability of primary care doctors to make accurate ratings of psychiatric disturbance and b) to evaluate the use of a case-finding questionnaire in the detection of psychiatric morbidity. The estudy took place in three primary care clinics in the city of São Paulo, Brazil, during a six-month survey. A time sample of consecutive adult attenders were asked to complete a case-finding questionnaire for psychiatric disorders (the Self Report Questionnaire - SRQ) and a subsample were selected for a semi-structured psychiatric interview (the Clinical Interview Schedule - CIS). At the end of the consultation the primary care doctors were asked to assess, in a standardized way, the presence or absence of psychiatric disorder; these assessments were then compared with that ratings obtained in the psychiatric interview. A considerable proportion of minor psychiatric morbidity remained undetected by the three primary care doctors: the hidden morbidity ranged from 22% to 79%. When these were compared to those of the case-finding questionnaire, they were consistently lower, indicating that the use of these instruments can enhance the recognition of psychiatric disorders in primary care settings. Four strategies for adopting the questionnaire are described, and some of the clinical consequences of its use are discussed.

JGIM plans to publish a special issue devoted to aspects of addressing alcohol, tobacco, and illicit drug use in patients seen in the primary care setting. This call for papers comes at a time when substance abuse issues are being recognized increasingly as mainstream general internal medicine concerns. This shift has occurred over the past decade as the importance of substance abuse disorders in medical practice has become well established. It has been estimated that alcohol consumption is responsible for over 100,000 deaths annually and over $100 billion in economic costs in the United States.1 When the impact of tobacco and illicit drug use is added to these figures, the total number of deaths per year increases to over 500,0002 and total economic costs are approximately one quarter of a trillion dollars.3 Underlying these findings regarding substance use-related mortality and costs is the fact that the use of alcohol, tobacco, and drugs has been closely linked to a variety of medical and psychosocial problems, all of which may prompt a visit to a primary care physician or health care facility. For example, over 25% of admissions to community hospitals are alcohol related4 and the prevalence of alcohol abuse or dependence ranges from 16 to 36% in outpatient medical settings.5 A recent study of adult primary care patients demonstrated that 60% used alcohol, of whom 9% were at-risk drinkers, 8% were problem drinkers and 5% were alcohol dependent.6 Data from this same study showed that 27% of these primary care patients used tobacco, and at least 20% had a history of illicit drug use, of whom 5% were current illicit drug users.6 Such studies give compelling evidence that substance use disorders are prevalent in primary care practice. Physicians need to be prepared to deal with these issues. Yet, we have a suboptimal record of identifying and addressing patients' needs in this regard in both inpatient and outpatient settings.4,7 Recognition of the importance of alcohol, tobacco, and other drug abuse disorders in primary care practice has resulted in a call for primary care physicians to take a larger role in the identification and management of substance use disorders.8–11 These disorders are after all quite similar to other problems managed by primary care physicians. They are characterized by a chronic course with periodic exacerbations and have both medical and psychosocial sequelae. Perhaps more importantly, these conditions can be identified by well-established screening methods and do respond to effective treatment. Recent research on the identification and treatment of substance use disorders has focussed on primary care settings. Increasingly, this research is being performed by investigators who are from fields such as General Internal Medicine, General Pediatrics, and Family Medicine. For example, major advances in the identification of effective screening methods for alcohol use disorders have been the result of research done in primary care settings by generalist physicians. As a result of this work, we now understand the utility of screening instruments such as the CAGE and the AUDIT and know the importance of early identification of alcohol problems.12–20 In addition, evidence is convincing that effective management of “at risk” and problem drinking and tobacco use can be delivered in the primary care setting.21–24 Even the treatment of illicit drug use with pharmacotherapies that historically were restricted to specialized treatment programs may soon become the province of primary care.25 The Society of General Internal Medicine's (SGIM) Substance Abuse Task Force has been at the forefront of these developments. The Task Force's members are among the leading investigators, educators, and clinicians in the substance abuse field. The group has taken a leadership role in bringing issues related to substance abuse “into the fold” of SGIM and generalist physicians in other fields.26 At the 2000 SGIM national meeting, the Task Force decided to seek publication of a special issue of JGIM which would focus on substance abuse. With the support of the Josiah Macy Foundation and the Physician Leadership on National Drug Policy (PLNDP), the Task Force will be sponsoring the publication of this issue entitled “Substance Abuse: Innovations in Primary Care” in early 2002. This special issue will follow standard JGIM format, with all articles focussed on aspects of alcohol, tobacco and illicit drug use relevant to generalist physicians. Authors may submit original research articles, brief reports, reviews, perspectives, reflections, or articles appropriate for the Journal's new sections on Health Policy, Populations at Risk, and Innovations in Education and Clinical Practice (see JGIM's instructions for authors at http://www.blackwellscience.com/journals/internal/form.html). The deadline for submission of articles is June 1, 2001. As Co-Chairs of the SGIM Task Force, we will serve as Co-Editors of this special issue. For further information concerning submission of original manuscripts or to volunteer to review articles, please contact Jeffrey Samet (ude.ub@temasj) or Patrick O'Connor (ude.elay@ronnoco.kcirtap).

Primary prevention of anxiety disorders in primary care: A systematic review

BackgroundThe primary health care setting is considered a major starting point in successful obesity management. However, research indicates insufficient quality of weight counseling in primary care. Aim of the present study was to implement and evaluate a 5A online tutorial aimed at improving weight management and provider-patient-interaction in primary health care. The online tutorial is a stand-alone low-threshold minimal e-health intervention for general practitioners based on the 5As guidance for obesity management by the Canadian Obesity Network.MethodsIn a cluster-randomized controlled trial, 50 primary care practices included 160 patients aged 18 to 60 years with obesity (BMI ≥ 30). The intervention practices had continuous access to the 5A online tutorial for the general practitioner. Patients of control practices were treated as usual. Primary outcome was the patients’ perspective of the doctor-patient-interaction regarding obesity management, assessed with the Patient Assessment of Chronic Illness Care before and after (6/12 months) the training. Treatment effects over time (intention-to-treat) were evaluated using mixed-effects linear regression models.ResultsMore than half of the physicians (57%) wished for more training offers on obesity counseling. The 5A online tutorial was completed by 76% of the physicians in the intervention practices. Results of the mixed-effects regression analysis showed no treatment effect at 6 months and 12 months’ follow-up for the PACIC 5A sum score. Patients with obesity in the intervention group scored lower on self-stigma and readiness for weight management compared to participants in the control group at 6 months’ follow-up. However, there were no significant group differences for weight, quality of life, readiness to engage in weight management, self-stigma and depression at 12 months’ follow-up.ConclusionTo our knowledge, the present study provides the first long-term results for a 5A-based intervention in the context of the German primary care setting. The results suggest that a stand-alone low-threshold minimal e-health intervention for general practitioners does not improve weight management in the long term. To improve weight management in primary care, more comprehensive strategies are needed. However, due to recruitment difficulties the final sample was smaller than intended. This may have contributed to the null results.Trial registrationThe study has been registered at the German Clinical Trials Register (Identifier: DRKS00009241, Registered 3 February 2016).

Health care reform should be driven by the goals of better patient experience, improved population health, lower per capita costs, and improved provider satisfaction. Electronic consultation (eConsult) services have been adopted by several jurisdictions in the United States, Canada, and Europe to improve access to specialists by primary care providers (PCPs) and are being heralded as a key component for delivery of coordinated care. The primary intent of an eConsult service is to provide PCPs with efficient, timely, direct access to specialist expertise to help guide the management of their patients, reduce the need for unnecessary face-to-face specialty consultations, and improve the quality of the initial face-to-face consultation when needed, through the preconsultative communication.In addition to improving access to care, eConsult services have been praised by PCPs and specialists for their educational value, in particular their ability to enrich practice-based learning. Less recognized, but equally important from the educational perspective, include the abilities of eConsult programs to promote reflection by PCPs and specialists, improve collegiality and professionalism between primary and specialist care, inform continuing professional development activities and maintenance of certification, and enhance training programs' teaching of effective communication and care coordination.As eConsult services become increasingly available, the medical community must leverage the educational opportunities inherent in eConsult programs to further improve the delivery of coordinated specialty care. The educational role of eConsults should be considered as a priority outcome in their evaluation and must be highlighted and optimized in next iterations of eConsult systems design.

Primary Care Takes Course on Cultural Issues in Depression

Physical activity counseling in primary health care is regarded as a useful complementary preventive and therapeutic measure and is advocated by leading public health institutions. This integrative review summarizes the available data on physical activity counseling in primary care in Germany. A systematic literature search in various databases (peer reviewed and grey literature) was carried out for quantitative and qualitative studies on physical activity counseling and use of “Exercise on Prescription”. The 25 studies included show a very high methodological diversity and, in some cases, considerable risks of bias, with limited comparability across studies. Counseling was provided in all studies by physicians. They report frequent physical activity counseling, which is partly confirmed and partly refuted by patient data. The use of “Exercise on Prescription” is at a very low level. Information on the frequency of physical activity counseling in Germany varies depending on data source and is sometimes contradictory. Our review provides a synthesis of various perspectives on routine physical activity counseling in primary care in Germany. Future studies using standardized and validated instruments in representative samples are needed to further knowledge on counseling and to be able to establish trends in prevalence. Strengthening the topics of physical activity and health and physical activity counseling in medical curriculum is strongly recommended.