Hospitalists and primary care.

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

To examine the association between 10-year temporal changes in the primary care workforce and Medicare beneficiaries' outcomes. 2001 and 2011 American Medical Association Masterfiles and fee-for-service Medicare claims. We calculated two primary care workforce measures within Primary Care Service Areas: the number of primary care physicians per 10,000 population (per capita) and the number of Medicare primary care full-time equivalents (FTEs) per 10,000 Medicare beneficiaries. The three outcomes were mortality, ambulatory care-sensitive condition (ACSC) hospitalizations, and emergency department (ED) visits. We measured the marginal association between changes in primary care workforce and patient outcomes using Poisson regression models. An increase of one primary care physician per 10,000 population was associated with 15.1 fewer deaths per 100,000 and 39.7 fewer ACSC hospitalizations per 100,000 (both p<.05). An increase of one Medicare primary care FTE per 10,000 beneficiaries was associated with 82.8 fewer deaths per 100,000, 160.8 fewer ACSC hospitalizations per 100,000, and 712.3 fewer ED visits per 100,000 (all p<.05). Medicare beneficiaries' outcomes improved as the number of primary care physicians and their clinical effort increased.

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.

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

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).

Individuals with serious mental illness often are unable to access consumer- and family-oriented community care, resulting in repeated hospitalizations, incarceration, and homelessness. The "medical home" concept was developed in primary care to provide accessible and accountable services for individuals with chronic medical conditions. Building on the work done in primary care, the authors propose a "mental health home." The model of care incorporates medical home characteristics, such as access to and coordination of services, integration of primary and preventive care, adoption of recovery orientation and evidence-based practices, and family and community outreach. Barriers to and strategies for implementation of mental health homes are discussed.

A New Kind of Homelessness for Individuals With Serious Mental Illness? The Need for a "Mental Health Home"

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

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

County-Level Estimates of Need for Mental Health Professionals in the United States

BackgroundIn the current context of increasingly fragmented healthcare systems where patients are seen by multiple doctors in different settings, patients’ relational continuity with one doctor is regaining relevance; however little is known about relational continuity with specialists. The aim of this study is to explore perceptions of relational continuity with primary care and secondary care doctors, its influencing factors and consequences from the viewpoint of users of the Catalan national health system (Spain).MethodsWe conducted a descriptive-interpretative qualitative study using a two-stage theoretical sample; (i) contexts: three healthcare areas in the Catalan national health system with differing characteristics; (ii) informants: users 18 years or older attended to at both care levels. Sample size (n = 49) was reached by saturation. Data were collected by individual semi-structured interviews, which were audio recorded and transcribed. A thematic content analysis was carried out segmenting data by study area, and leaving room for new categories to emerge from the data.ResultsPatients across the areas studied generally experienced consistency of primary care doctors (PCD), alongside some inconsistency of specialists. Consistency of specialists did not seem to be relevant to some patients when their clinical information was shared and used. Patients who experienced consistency and frequent visits with the same PCD or specialist described and valued having established an ongoing relationship characterised by personal trust and mutual accumulated knowledge. Identified consequences were diverse and included, for example, facilitated diagnosis or improved patient-doctor communication. The ascription to a PCD, a health system-related factor, facilitated relational continuity with the PCD, whereas organizational factors (for instance, the size of the primary care centre) favoured consistency of PCD and specialists. Doctor-related factors (for example, high technical competence or commitment to patient care) particulary fostered the development of an ongoing relationship.ConclusionsConsistency of doctors differs depending on the care level as does the relevance attributed to it. Most influencing factors can be applied to both care levels and might be addressed by healthcare managers to foster relational continuity. More research is needed to fully understand the relevance patients assign to relational continuity with specialists.

One Stop Health Care Shopping? The Rise of “McClinics” and Their Impact on Emergency Care

Liaison and Consultation Psychiatry

The contributions of primary care to improvements in many aspects of population and individual health are well documented (Starfield, Shi, and Macinko 2005). In addition to the health benefits, there are reductions in health system costs and reductions in disparities in health across population subgroups. The findings are robust over time and across areas and health systems. International comparisons show that countries with health systems based on strong primary care have better health at lower costs. Studies within countries, including both industrialized as well as middle income and developing countries, are consistent in showing greater improvements in health consequent to legislative and administrative policy initiatives directed at strengthening primary care, including increases in the supply and use of primary care practitioners and clinical improvements in primary care practice. The special and critical features of primary care are well known and include first contact access and use of primary care facilities and practitioners; person-focused (not disease-focused) care over time; comprehensiveness of services available and provided within primary care; and coordination of services when they are needed elsewhere (Starfield, Shi, and Macinko 2005).

Primary care physicians play unique roles caring for complex patients, often acting as the hub for their care and coordinating care among specialists. To inform the clinical application of new models of care for complex patients, we sought to understand how these physicians conceptualize patient complexity and to develop a corresponding typology. We conducted qualitative in-depth interviews with internal medicine primary care physicians from 5 clinics associated with a university hospital and a community health hospital. We used systematic nonprobabilistic sampling to achieve an even distribution of sex, years in practice, and type of practice. The interviews were analyzed using a team-based participatory general inductive approach. The 15 physicians in this study endorsed a multidimensional concept of patient complexity. The physicians perceived patients to be complex if they had an exacerbating factor-a medical illness, mental illness, socioeconomic challenge, or behavior or trait (or some combination thereof)-that complicated care for chronic medical illnesses. This perspective of primary care physicians caring for complex patients can help refine models of complexity to design interventions or models of care that improve outcomes for these patients.