Impact of COVID-19 on Primary Care Practice Sites and Their Vulnerable Patients.

Despite evidence suggesting that high-quality primary care can prevent unnecessary hospitalizations, many primary care practices face challenges in achieving this goal, and there is little guidance identifying effective strategies for reducing hospitalization rates. We aimed to understand how practices in the Comprehensive Primary Care Plus (CPC+) program substantially reduced their acute hospitalization rate (AHR) over 2 years. We used Bayesian analyses to identify the CPC+ practice sites having the highest probability of achieving a substantial reduction in the adjusted Medicare AHR between 2016 and 2018 (referred to here as AHR high performers). We then conducted telephone interviews with 64 respondents at 14 AHR high-performer sites and undertook within- and cross-case comparative analysis. The 14 AHR high performers experienced a 6% average decrease (range, 4% to 11%) in their Medicare AHR over the 2-year period. They credited various care delivery activities aligned with 3 strategies for reducing AHR: (1) improving and promoting prompt access to primary care, (2) identifying patients at high risk for hospitalization and addressing their needs with enhanced care management, and (3) expanding the breadth and depth of services offered at the practice site. They also identified facilitators of these strategies: enhanced payments through CPC+, prior primary care practice transformation experience, use of data to identify high-value activities for patient subgroups, teamwork, and organizational support for innovation. The AHR high performers observed that strengthening the local primary care infrastructure through practice-driven, targeted changes in access, care management, and comprehensiveness of care can meaningfully reduce acute hospitalizations. Other primary care practices taking on the challenging work of reducing hospitalizations can learn from CPC+ practices and may consider similar strategies, selecting activities that fit their context, personnel, patient population, and available resources.

Implementing Programs for Chronic Illness Management: The Case of Hypertension Services

To investigate the effect of changes in body mass index (BMI) on health state preferences (HSP). Multiple regression analysis on pooled data from a clinical study, predicting final HSP as a function of changes in BMI and initial HSP, controlling for age and gender. Subgroup analyses according to clinically relevant subgroups were performed. Primary care practice sites. 402 obese patients of varying disease severity. BMI was operationalised as (weight in kilograms)/ (height in metres)(2). HSP were measured directly as visual analogue scale (VAS) scores, and converted to time trade-off (TTO) scores. A one unit decrease in BMI over a 1-year period was associated with a 0.017 gain in utility units (utils). This estimate is comparable to utility gains observed for other widely used treatments (e.g. revascularisation for intermittent claudication, renal transplantation). It varies little over the observed range of VAS to TTO conversion values, and is a conservative estimate compared with using the unconverted VAS scores. If attempts to use weight reduction treatment in only the patients who successfully meet strict weight reduction targets are successful, the gain in HSP experienced by such patients may exceed this estimate. Patients with BMI values >or=28 with hyperglycaemia appear to have the greatest gain in HSP for a given change in BMI over 1 year. The effect of weight reduction on HSP can be significant, at least in the short term. Estimates of HSP changes presented herein may be useful in economic evaluations of weight reduction treatments.

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).

The recent article in this journal regarding attention deficit hyperactivity disorder (ADHD) treatment1 provides an interesting snapshot of clinical practice. I write to extend discussion of their findings. The authors drew two potentially contradictory conclusions. The first was that practice falls in line with the recent draft NHMRC guidelines. Secondly, they identified considerable variation in prescription and treatment practice by profession, sector, duration of time in practice, practice size and focus, and location. If these conclusions are concurrently valid, the guidelines must encompass a significant degree of practice diversity. Is this ideal? Variability in practice can reflect local opportunities and limitations2 and accordingly may have adaptive advantages. Variation in practice may also be acceptable if clinical outcomes are relatively independent of practice activities and pathways. In other chronic medical conditions, however, where medical intervention is part of a comprehensive longitudinal strategy, I believe such variability would be considered undesirable and potentially detrimental to child health. With conditions such as diabetes and cystic fibrosis we have a variety of markers by which to monitor the cumulative impact of the disorder. By evaluating practice against these measures, particularly over long periods of time, consensus has emerged regarding which practices optimise not only short-term but particularly long-term health and well-being. As a result, variability in practice is reduced. For ADHD this is a complex challenge. The main clinical measure of disorder and related intervention for ADHD is behavioural symptom profile as determined by observational rating scales. This provides only limited information regarding current and cumulative impact of the disorder. The challenge further includes the scope of impact of ADHD in the lives of developing children. Variability around what clinicians consider to be their scope of care and related outcomes is clearly reflected in this study. The impairment attributable to ADHD relates not only to the symptoms but also to the demands of the context in which they manifest. Long-term well-being relates to a diverse set of secondary consequences across child development, mental health and social function3 rather than just the primary pathology. This situation may never change while we continue to manage children with diagnoses taken from the Diagnosis and Statistical Manual of Mental Disorders IV alone and measures of symptom expression. What are the short- and long-term measures of outcome against which we more effectively consider best practice?

85 Background: While evidence-based guidelines for survivorship care exist, implementation in oncology and primary care practices has fallen short. There is little evidence of the barriers preventing successful implementation in rural primary care and oncology practices. We sought to assess knowledge gaps and barriers to successful implementation of evidence-based survivorship care guidelines in rural Kansas practices. Methods: Midwest Cancer Alliance, outreach arm of the University of Kansas Cancer Center, and Kansas Patients and Providers Engaged in Prevention Research, completed interviews in rural primary care and oncology practices. Results: Primary Care (n=7) and Oncology Practices (n=4): Interviews with primary care physicians, medical oncologists, advanced practice providers, nurses, tumor registrar, outreach coordinator, and office management & staff. Conclusions: Rural primary care and oncology practices experienced barriers to delivering survivorship care including: educational gaps, communication of history, treatment, and recommendations, EHR integration, and lack of resources. Next steps focus on a unified approach to state-wide survivorship education of patients, primary care and oncology practices. [Table: see text]

Independent foundations' primary focus is grant making.In general, their assets come from the gift of an individual or family.Community foundations' assets usually come from many donors rather than a single source, and grant making is limited to a particular region.Community foundations are usually classified as private charities under the tax law and are subject to different rules and regulations than are other private foundations. Access To CareAccording to 1988 Census Bureau estimates, over thirty-one million Americans are without health insurance.The demographics of these people are diverse, and their ranks continue to grow as the service industry burgeons and as competition in health care increases.Regional disparities in access also exist.Foundation funding in this area ranges from economic analyses of the problem to direct provision of care.

Exploring the Generalist-Subspecialist Interface in Internal Medicine

The principal goals of health care reform are to improve quality, increase access, and contain costs. In this issue, Pham and colleagues calculated that a typical primary care clinician must coordi...

Collaborative Care Rises to the Pandemic Challenge

In 2004, the American Academy of Pediatrics (AAP) Board of Directors formed the Task Force on Mental Health and charged it with developing strategies to improve the quality of child and adolescent mental health* services in primary care. The task force acknowledged early in its deliberations that enhancing the mental health care that pediatricians and other primary care clinicians† provide to children and adolescents will require systemic interventions at the national, state, and community levels to improve the financing of mental health care and access to mental health specialty resources. Systemic strategies toward achieving these improvements are the subject of other publications of the task force: “ Strategies for System Change in Children's Mental Health: A Chapter Action Kit ” (chapter action kit),1 “Improving Mental Health Services in Primary Care: Reducing Administrative and Financial Barriers to Access and Collaboration,”2 and “Enhancing Pediatric Mental Health Care: Strategies for Preparing a Community.”3 The task force also recognized that enhanced mental health practice will require competencies not currently achieved by many primary care clinicians; in the policy statement “The Future of Pediatrics: Mental Health Competencies for Pediatric Primary Care,”4 the task force collaborated with the AAP Committee on Psychosocial Aspects of Child and Family Health to outline these competencies and propose strategies for achieving them. This report offers strategies for preparing the primary care practice itself for provision of enhanced mental health care services. The task force proposes incrementally applying chronic care principles to the care of children with mental health and substance abuse problems as primary care clinicians apply them to the care of children with chronic medical conditions such as asthma. Most primary care clinicians will find that significant gaps exist between their current practice and the proposed ideal. The task force offers guidance in … Address correspondence to Jane Meschan Foy, MD, Department of Pediatrics, Wake Forest University School of Medicine, Medical Center Blvd, Winston-Salem, NC 27157. E-mail: jmfoy{at}wfubmc.edu

Despite prior focus on high-impact inpatient cases, there are increasing data and awareness that malpractice in the outpatient setting, particularly in primary care, is a leading contributor to malpractice risk and claims. To study patterns of primary care malpractice types, causes, and outcomes as part of a Massachusetts ambulatory malpractice risk and safety improvement project. Retrospective review of pooled closed claims data of 2 malpractice carriers covering most Massachusetts physicians during a 5-year period (January 1, 2005, through December 31, 2009). Data were harmonized between the 2 insurers using a standardized taxonomy. Primary care practices in Massachusetts. All malpractice claims that involved primary care practices insured by the 2 largest insurers in the state were screened. A total of 551 claims from primary care practices were identified for the analysis. Numbers and types of claims, including whether claims involved primary care physicians or practices; classification of alleged malpractice (eg, misdiagnosis or medication error); patient diagnosis; breakdown in care process; and claim outcome (dismissed, settled, verdict for plaintiff, or verdict for defendant). During a 5-year period there were 7224 malpractice claims of which 551 (7.7%) were from primary care practices. Allegations were related to diagnosis in 397 (72.1%), medications in 68 (12.3%), other medical treatment in 41 (7.4%), communication in 15 (2.7%), patient rights in 11 (2.0%), and patient safety or security in 8 (1.5%). Leading diagnoses were cancer (n = 190), heart diseases (n = 43), blood vessel diseases (n = 27), infections (n = 22), and stroke (n = 16). Primary care cases were significantly more likely to be settled (35.2% vs 20.5%) or result in a verdict for the plaintiff (1.6% vs 0.9%) compared with non-general medical malpractice claims (P < .001). In Massachusetts, most primary care claims filed are related to alleged misdiagnosis. Compared with malpractice allegations in other settings, primary care ambulatory claims appear to be more difficult to defend, with more cases settled or resulting in a verdict for the plaintiff.

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).

Expanded roles of registered nurses in primary care delivery of the future

Registered nurses in primary care: A value proposition