Research letter: Do physicians discuss

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.

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

There is a widespread perception that the increasing proportion of female physicians in most developed countries is contributing to a primary care service shortage because females work less and provide less patient care compared with their male counterparts. There has, however, been no comprehensive investigation of the effects of primary care physician (PCP) workforce feminization on service supply. We undertook a systematic review to examine the current evidence that quantifies the effect of feminization on time spent working, intensity and scope of work, and practice characteristics. We searched Medline, Embase, and Web of Science from 1991 to 2013 using variations of the terms ‘primary care’, ‘women’, ‘manpower’, and ‘supply and distribution’; screened the abstracts of all articles; and entered those meeting our inclusion criteria into a data abstraction tool. Original research comparing male to female PCPs on measures of years of practice, time spent working, intensity of work, scope of work, or practice characteristics was included. We screened 1,271 unique abstracts and selected 74 studies for full-text review. Of these, 34 met the inclusion criteria. Years of practice, hours of work, intensity of work, scope of work, and practice characteristics featured in 12%, 53%, 42%, 50%, and 21% of studies respectively. Female PCPs self-report fewer hours of work than male PCPs, have fewer patient encounters, and deliver fewer services, but spend longer with their patients during a contact and deal with more separate presenting problems in one visit. They write fewer prescriptions but refer to diagnostic services and specialist physicians more often. The studies included in this review suggest that the feminization of the workforce is likely to have a small negative impact on the availability of primary health care services, and that the drivers of observed differences between male and female PCPs are complex and nuanced. The true scale of the impact of these findings on future effective physician supply is difficult to determine with currently available evidence, given that few studies looked at trends over time, and results from those that did are inconsistent. Additional research examining gender differences in practice patterns and scope of work is warranted.

Fulfilment of patients' expectations has been associated with greater patient satisfaction with care and greater adherence to medical advice. However, little is know about how race influences patient expectations. To determine the association between patient race and patient expectations of their primary care physician. The design was a cross-sectional study. Setting and participants were sample of 709 primary care patients from four clinic sites at the Philadelphia Veterans Affairs Medical Center and the University of Pennsylvania Health System. The measures were an expectations instrument asking patients to rate the necessity of the physician performing 13 activities during the index visit, self-reported race, demographics, the Rapid Estimate of Adult Literacy in Medicine, the Charlson Comorbidity Index and SF-12. After adjusting for age, sex, education, clinic site, comorbidity, health literacy and health status, African Americans were more likely to report it was absolutely necessary for the physician to refer them to a specialist [AOR 1.55 (95% confidence interval, CI, 1.09-2.21), P = 0.01], order tests [AOR 1.59 (95% CI 1.11-2.27), P = 0.01] and conduct each of the six physical exam components. African American race is associated with greater expectations of the primary care physicians. More research is needed to confirm the differential expectations by race and determine the reasons for the differential expectations.

Community-driven network building in health care: creating an exploratory social space to pursue co-production following reformsIntroduction:Integrated care requires engaging and empowering people and communities to take an active role in designing and delivering health services (WHO 2019). Their capacities to co-produce health outcomes alongside formal providers are key to assuring sustainability and equity. However collaborative dynamics are compromised by power differentials that limit recognition of community capacities, and are vulnerable to system reforms. Much of the literature on co-production focuses on provider-side initiatives to engage communities. This paper provides an alternate view, exploring how community actors forge network alliances to gain legitimacy and power to co-produce care.Methods:We conducted a longitudinal case study of the network development efforts of a community working group (WG) concerned with access to health services following reforms in Québec, Canada. The WG brought together concerned citizens along with community organizations working with seniors, minorities, immigrants, youth, and people with disabilities. Data were collected over three years from observation, documents and interviews, and social network analysis was conducted to reveal the evolution of relationships among community actors, and between community and public actors. Actor-network theory (Callon) was used to distinguish stages of network maturation. These analyses explored how interactions contributed to identifying and opening pathways for co-production.Results:The WG pursued network building in two stages. A first focused on problem definition: WG members brought their existing networks together to validate access problems perceived in their constituencies, then reached out as a group to public sector contacts to achieve a better understanding of precisely what had changed in the system. In a second stage, the WG mobilized this network of community and public actors to equip a broader public to more effectively draw upon public and community resources to meet their needs. Two factors appeared to impede co-production: the limited influence of front-line actors on public system processes; and discrepancies between community priorities and system mechanisms for participation.Discussion:In the context of reforms, 'problematization' was an especially important stage in network development and showed signs of consensus development on 1. the existence and nature of problems, and 2. interdependencies between public and community actors in identifying and implementing solutions.Conclusions:Network development through the WG enabled community actors to gain the "organizational infrastructure" to participate in collaborative governance (Ansell and Gash 2008). Community efforts can open new spaces to enhance co-productive capacities of people and communities; public provider ability to integrate these capacities into processes is reduced by reforms.Lessons:Network interactions enable the recognition of interdependencies and the development of consensus, and in this way create conditions for collaboration even among actors of different strengths (Benson).The fragility and disruption through reforms of links between public and community actors impede co-production.LimitationsLonger follow-up and comparison with other community initiatives may have provided additional insight into community strategies for gaining legitimacy in co-production.Future researchResearch on factors limiting the effectiveness of longstanding 'concertation' venues after reforms would be helpful, as would exploration of territorial dimensions of co-production between public and community actors in healthcare services.

The world we live in: Health policy from a primary care perspective

Summary The study has been conducted in January-February 2003. And the second study in March-May 2007. The questionnaires were given to every 10th patient over 18 years old, who registered for the first time during the episode. Questionnaires were distributed among 500 patients, 343 questionnaires were returned to the study team (response rate 68,6 percent). Study participants were asked their opinion about the institution where their primary care physician should work. 50 percents of employers and 86,9 percents of housewives preferred that family physician’s office should be situated near their living place. 50 percents of unemployed respondents as well as 47 percents of employees wished that their family physicians, narrow specialists and laboratories should be working in one building. 72 percent of respondents who earn 1001-1500 Litas (Lt) per month for one family member thought that it is more comfortable when their doctors work in their neighbourhood. Respondents with monthly income 1501-2000 Lt and more per for one family member (61,1 percent and 45,7 percent accordingly) had different opinion: they preferred that all primary and secondary care physicians and laboratories were situated in one building. Only 14,6 percent of retired study participants have not heard about possibility to be treated in day-hospitals in outpatient clinics. Students and schoolchildren were those who were mostly not informed about this possibility (73,9 percent). But most of the students and schoolchildren were positive that in case they need hospital treatment, preference would be given to day-hospital clinics (74,3 percent). Majority of housewives (71,3 percent), and businessmen (55,2 percent) would also prefer day-hospital clinics. Choice of retired and unemployed respondents were distributed almost equally: 53,8 percent of retired persons and 33,3 percent of unemployed would choose day-hospital clinics; 46,2 percent of retired and 52,2 percent of unemployed would prefer treatment in hospital. No statistically significant dependence was found between income for one family member and preferred choice of treatment. Respondents who earn more than 2000 Lt for one family member noted that in case they need hospital treatment, they would certainly choose day-hospital clinics (100 percent). Two thirds of study participants (67,9 percent) had negative opinion concerning offered innovation – that family doctor replaced earlier primary care physicians team consisting of district therapeutist, paediatrician, gynaecologist and surgeon. Most of those who had negative opinion were retired persons (81,7 percent), businessman (72,4 percent), technical employees, workers (71 percent) and housewives (69,8 percent). 86,0 percent of respondents reported that first physician they usually contacted was their family doctor. Most of them were retired parsons, students and schoolchildren, workers/technical employees and housewives (92,5 percent, 91,3 percent, 91 percent and 89,3 percent accordingly). Businessman (34,5 percent) preferred to contact the physician that they knew personally, superlatives and managers (14,3 percent) mostly referred to private physicians. 53,9 percent of respondents positively evaluated functioning of health care institutions. 88,2 percent of respondents with income 1501-2000 Lt per month for one family member evaluated it well or very well, the same opinion had 74 percent of respondents earning income 1001-1500 Lt per month. 63,3 percent of respondents with average income up to 500 Lt per month work of health care institutions assessed as satisfactory. Respondents who earn more than 2000 Lt per month per family member assessed functioning of health care institutions as follows: 20 percent – very good, 31,4 percent – good, 37,1 percent – satisfactory and 11,4 percent – bad.

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

The American Academy of Pediatrics (AAP) policy statement entitled “The New Morbidity Revisited: A Renewed Commitment to the Psychosocial Aspects of Pediatric Care”1 from the Committee on Psychosocial Aspects of Child and Family Health is found in this month's issue of Pediatrics . Few experienced pediatric practitioners would disagree with this description of our life's work. Most embrace this “renewed commitment” to relevant and comprehensive care for our children and families. It is not hard to look past the examination room and appreciate the struggles, tensions, and morbidities that this complex world presents our patients as they grow and develop. But what about the complex world of our practices? We are well-intended, but are we well-trained, and are we able to follow through on our “commitment”? “ Mental health needs of children and adolescents are increasing while access to behavioral health, mental health, and substance abuse service is decreasing .”2 The rate of psychosocial problems identified by primary care physicians in the children they care for has increased from 7% to 18% in the past 20 years. Information accumulated by the Pediatric Research in Office Settings (PROS) group3 confirmed what practicing pediatricians already know: the children we see for earaches bring with them symptoms of their behavioral health. These children may have attentional difficulties, conduct issues, or significant problems of mood. They may suffer acute adjustment difficulties or evidence posttraumatic stress from physical, emotional, or sexual abuse, and may experience family poverty, family divorce, or a host of other intrinsic or situational problems that impact on their health and the ability of their family and caregivers to provide for their health. We are seeing more problems and, lacking referral sources, often have to provide more care. Skills needed to address the new morbidities are part of our …

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

Research ObjectiveTo alleviate the problem of primary care physician (PCP) shortage, policy makers have established new medical schools and expanded medical school class sizes over the last 15 years. However, few studies have examined whether the increased PCP supply improves access to care. We aimed to fill the gap by examining the effect of PCP supply on adults’ access to care and assessing the extent to which market adjustments mitigate PCP shortages.Study DesignWe used primary care service areas (PCSAs) as market areas and merged PCSA‐level PCP supply (PCPs per 1000 population) with individual‐level data from the 2004‐2013 Medical Expenditures Panel Survey (MEPS). The data on physician supply and number of patients that PCPs saw per day came from SK&A while all other measures were from the MEPS.We modeled the probability that adults had a nonemergency room usual source of care (USC) as a function of PCP supply and individual sociodemographic characteristics, health status, and beliefs and attitudes regarding health and health care. We estimated analogous models to examine how PCP supply affects travel time to the USC and the ability to get needed care right away and make appointments as soon as needed. To examine market adjustments, we assessed the relationship between PCP supply and whether PCPs offered night and weekend hours, how many patients PCPs saw per day, and how frequently individual adults had office visits. As sensitivity analyses, we tested alternative PCP definitions (eg, including vs. excluding obstetricians/gynecologists) and estimated the models separately for adults with and without health insurance. All the models controlled for nurse practitioners and physician assistants.Population Studied378 400 adults included in the 2004‐2013 MEPS.Principal FindingsPCP supply had no effect on the probability of having a USC or the ability to get needed care right away or make timely appointments by adults. By contrast, higher PCP supply reduced adults’ travel time to the USC. We also found evidence of market adjustments that enhanced the physicians’ capacity to see different patients in areas with low PCP supply. Specifically, PCPs in these areas were more likely to offer night and weekend hours and saw more patients per day (elasticity at mean = −0.19), while adults in these areas had fewer office visits (elasticity at mean = 0.07). Taken together, the latter two adjustments compensate for more than one‐fourth of the lost capacity to see different patients where there are fewer PCPs. The sensitivity analyses confirmed robustness of the results.ConclusionsSince both having a USC and the ability to get timely care when needed and make timely appointments are likely to be more important indicators of access than travel time to the USC, our findings suggest that more PCPs do not improve the most important access indicators for most U.S. adults. Market adjustments in areas with fewer PCPs are at least partly responsible for the lack of effects of PCP supply on having a USC.Implications for Policy or PracticeProducing more physicians may be a blunt instrument for improving access to care. Targeted policies are likely to be more efficient in improving access for adults who currently lack it.Primary Funding SourceAgency for Healthcare Research and Quality.

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

Patient's and Doctor's Delay in the Diagnosis of Multiple Myeloma and Waldenströms Macroglobulinemia: The Results of An Inventarisation and Follow-up Study by the CKP the Dutch Advocacy Group for Patients in the Netherlands

Gout, the most common inflammatory arthritis in developed countries, can lead to deformities and disabilities, significantly affecting quality of life. Primary care physicians (PCPs) play a crucial role in its management and must adhere to recent guidelines. This study assessed PCPs’ knowledge and adherence to gout treatment recommendations in Saudi Arabia using a questionnaire survey. A total of 367 PCPs completed the survey, with 86.4% practicing in Saudi Arabia. The respondents included general physicians (53.1%) and family physicians (49.9%), with a nearly equal gender distribution. For acute gout management, 25.34% recommended nonsteroidal anti-inflammatory drugs combined with corticosteroids. Colchicine was considered safe by 69.8% of participants. Knowledge of urate-lowering therapy was suboptimal, with only 7.9% correctly identifying the appropriate initiation timing and 43.1% recognizing the target serum uric acid (SUA) level. While 74.1% recommended modifying therapy if the SUA target was unmet, only 32% advocated for long-term urate-lowering therapy. Additionally, 18% correctly identified the proper time to measure SUA levels. Lifestyle modifications were acknowledged by 57.2%, and 55% recognized the cardiovascular risks associated with gout. Overall, PCPs demonstrated poor compliance with gout management guidelines. Strategies to improve adherence include continuing medical education, disease-management websites, and smartphone apps. Rheumatologists should serve as key resources for PCPs, providing education through consultations, formal training, and conference presentations.

OBJECTIVE Glioblastoma (GBM) is an aggressive brain malignancy with a short overall patient survival, yet there remains significant heterogeneity in outcomes. Although access to health care has previously been linked to impact on prognosis in several malignancies, this question remains incompletely answered in GBM. METHODS This study was a retrospective analysis of 354 newly diagnosed patients with GBM who underwent first resection at the authors' institution (2007-2015). RESULTS Of the 354 patients (median age 61 years, and 37.6% were females), 32 (9.0%) had no insurance, whereas 322 (91.0%) had insurance, of whom 131 (40.7%) had Medicare, 45 (14%) had Medicaid, and 146 (45.3%) had private insurance. On average, insured patients survived almost 2-fold longer (p < 0.0001) than those who were uninsured, whereas differences between specific insurance types did not influence survival. The adjusted hazard ratio (HR) for death was higher in uninsured patients (HR 2.27 [95% CI 1.49-3.33], p = 0.0003). Age, mean household income, tumor size at diagnosis, and extent of resection did not differ between insured and uninsured patients, but there was a disparity in primary care physician (PCP) status-none of the uninsured patients had PCPs, whereas 72% of insured patients had PCPs. Postoperative adjuvant treatment rates with temozolomide (TMZ) and radiation therapy (XRT) were significantly less in uninsured (TMZ in 56.3%, XRT in 56.3%) than in insured (TMZ in 75.2%, XRT in 79.2%; p = 0.02 and p = 0.003) patients. Insured patients receiving both agents had better prognosis than uninsured patients receiving the same treatment (9.1 vs 16.34 months; p = 0.025), suggesting that the survival effect in insured patients could only partly be explained by higher treatment rates. Moreover, having a PCP increased survival among the insured cohort (10.7 vs 16.1 months, HR 1.65 [95% CI 1.27-2.15]; p = 0.0001), which could be explained by significant differences in tumor diameter at initial diagnosis between patients with and without PCPs (4.3 vs 4.8 cm, p = 0.003), and a higher rate of clinical trial enrollment, suggesting a critical role of PCPs for a timelier diagnosis of GBM and proactive cancer care management. CONCLUSIONS Access to health care is a strong determinant of prognosis in newly diagnosed patients with GBM. Any type of insurance coverage and having a PCP improved prognosis in this patient cohort. Higher rates of treatment with TMZ plus XRT, clinical trial enrollment, fewer comorbidities, and early diagnosis may explain survival disparities. Lack of health insurance or a PCP are major challenges within the health care system, which, if improved upon, could favorably impact the prognosis of patients with GBM.