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September/October 2012 Annals of Family Medicine tip sheet

Extended Office Hours Associated with Lower Health Expenditures

Patients who have access to a regular source of health care that offers evening and weekend hours have significantly lower health expenditures than those who do not. Analyzing data on more than 30,000 patients from the 2000-2008 Medical Expenditure Panel Surveys, researchers found total expenditures were 10 percent lower among patients reporting access to extended hours in two successive years compared with those lacking such access. The researchers link the association to lower prescription drug and office visit-related (e.g., testing) expenditures. Importantly, the reduced expenditures did not have any apparent adverse effects on mortality. The authors call for future research to formally test their hypothesis that extended office hours may be associated with relatively judicious use of primary health care resources, including more generic medication prescribing and less discretionary testing.

Extended Office Hours and Health Care Expenditures: A National Study

By Anthony Jerant, MD, et al

University of California Davis School of Medicine, Sacramento

Cancer Survivors Express Concerns About Seeing Primary Care Physicians for Follow-Up Care

Nearly one-third of office visits for cancer are handled by primary care physicians, yet this study finds cancer survivors have concerns about seeing their primary care physician for cancer-related follow-up care. Exploring survivor preferences through in-depth interviews with 42 cancer patients, researchers found 52 percent expressed strong preferences to receive follow-up from their cancer specialists. They described several barriers to the primary care physician's engagement in follow-up, including 1) lack of cancer expertise, 2) limited or no involvement with original cancer care, and 3) lack of care continuity. Only one-third of participants (38 percent) believed there was a role for primary care clinicians in cancer follow-up care, suggesting these opportunities: 1) performing routine preventive screening tests, 2) supplementing cancer-related specialist care, and 3) providing follow-up medical care when "enough time had passed" or the survivors felt they could reintegrate into the noncancer population. These findings, the authors assert, point to a need for primary care to engage meaningfully in the case management of the growing population of cancer survivors. They call for future research and interventions that address both patient and patient-perceived physician knowledge gaps related to cancer follow-up care.

Adult Cancer Survivors Discuss Follow-up in Primary Care: 'Not What I Want, But Maybe What I Need'

By Shawna V. Hudson, PhD

The Cancer Institute of New Jersey, New Brunswick

Primary Care Utilization Associated with Better Breast Cancer Outcomes

Medicare beneficiaries with breast cancer who had a greater number of visits to primary care physicians in the two years preceding their diagnosis have better breast cancer outcomes, including greater use of mammography, reduced odds of late-stage diagnosis, and lower overall and breast cancer mortality. Analyzing data on more than 105,000 female Medicare beneficiaries with breast cancer, researchers found women who had 10 or more office visits were 50 percent less likely to have late-stage cancer diagnosed and had 41 percent lower breast cancer mortality, as well as 27 percent lower overall mortality, compared with women having one or no visits. The authors assert the improved outcomes are partly explained by greater use of mammography and resultant earlier stage diagnosis. The authors conclude the findings suggest adequate primary medical care may be an important factor in achieving optimal outcomes for breast cancer patients.

Influence of Primary Care on Breast Cancer Outcomes Among Medicare Beneficiaries

By Richard G. Roetzheim, MD, MSPH

University of South Florida

New Team Models Could Provide Care for Panel Sizes Achievable With the Available Primary Care Workforce

Primary care is facing the dilemma of excessive patient panel sizes the average primary care physician's panel size of 2,300 is too large for delivering good care under the traditional practice model in an environment of primary care workforce shortage, which means panel size will only increase. This mismatch has given rise to a delegated team model of primary care whereby an interdisciplinary mix of team members is responsible for patient care. Using published estimates of the time it takes for a primary care physician to provide preventive, chronic and acute care, researchers from the University of California at San Francisco offer estimates of what panel sizes might be reasonable if portions of these services were delegated to nonphysician team members. They conclude that depending on the degree of task delegation, a primary care team could reasonably care for panel sizes achievable with the available primary care workforce. Specifically, using three assumptions about the degree of task delegation that could be achieved (77 percent, 60 percent, and 50 percent of preventive care, and 47 percent, 30 percent and 25 percent of chronic care), they estimate a primary care team could care for a panel of 1,947, 1,523, or 1,397 patients. The authors conclude the replacement of physician-only care with team-based care will require a significant change in the culture and structure of primary care practice, but high-functioning primary care teams have the potential to both ensure access and quality for the nation's population and provide a reasonable work life for physicians and other team members.

Estimating a Reasonable Patient Panel Size for Primary Care Physicians With Team-Based Task Delegation

By Justin Altschuler, MD, et al

University of California at San Francisco

A Perspective on the Dramatic Increase in Pharmaceutical Management of Chronic Illness in Primary Care: Underlying Influences and Unintended Outcomes

With 45 percent of the U.S. population having been diagnosed with a chronic condition and 40 percent of people older than 60 taking five or more medications, researchers raise questions about the nature of the relationship between the expanding definition of chronic illness and the explosion in pharmaceutical use in the United States. Using a convenience sample of 58 primary care clinicians in Michigan and 70 of their patients being treated for diabetes, hypertension or both, the authors examine some factors contributing to the dramatic rise is chronic illness diagnoses and associated polypharmacy. They suggest these trends result from a number of influences, most notably 1) increasingly lower diagnostic and treatment thresholds for common chronic conditions, 2) clinician auditing and reward systems, and 3) a prescribing cascade, whereby more medications are prescribed to control the effects of already-prescribed medications. The authors identified several challenges to patient well-being resulting from the heavy reliance on pharmaceuticals, notably financial costs and adverse drug effects. They present a conceptual model, the inverse benefit law, to provide insight into the impact of pharmaceutical marketing efforts on the observed trends. To reverse these trends and limit the influence of the pharmaceutical industry on clinical practice, the authors call for 1) policies that will exclude individuals or organizations with financial conflicts of interest from involvement with clinical guideline-writing panels, 2) physicians to be discouraged from seeing drug representatives, and 3) the monitoring of clinician auditing and reward plans for evidence of unintended negative effects on patients.

The Changing Face of Chronic Illness Management in Primary Care: A Qualitative Study of Underlying Influences and Unintended Outcomes

By Linda M. Hunt, PhD, et al

Michigan State University

UK's Quality and Outcomes Framework Delivers Modest Improvements in Quality

A systematic review of the growing body of evidence regarding the United Kingdom's Quality and Outcomes Framework, arguably the most comprehensive national primary care pay-for-performance scheme in the world, finds modest improvements in quality of care since its introduction in 2004. The review, which included 94 studies, found the QOF was associated with an increased rate of improvement of quality of care for incentivized conditions during the first year of implementation, returning to preintervention rates of improvement in subsequent years. It also found modest cost-effective reductions in mortality and hospital admissions in some domains. The analysis showed the QOF has led to narrowing of differences in performance in deprived areas compared with nondeprived areas. Some doctors reported improved data recording and teamwork, and nurses reported enhanced specialist skills. Both groups, however, believed the patient-centeredness of consultations and continuity were negatively affected by QOF. Remarkably little is known of what patients make of the changes, although anecdotal reports point to unintended consequences detracting from patient-centered care. In view of the findings, the authors recommend policy makers continue to exercise caution about implementing similar schemes, and they call for future research into how to improve quality across different domains while minimizing costs and any unintended adverse effects.

Pay-for-Performance in the United Kingdom: Impact of the Quality and Outcomes Framework A Systematic Review

By Stephen J. Gillam, MD, FFPH, FRCP, FRCGP, et al

University of Cambridge, England

Consumers Desire Greater Control Over their Electronic Health Information

Patients in New York, a state where patients must actively consent to having their data accessed through health information exchange, are generally supportive of the electronic sharing of health information and are willing to have their health information automatically stored in an HIE; however, they want to have control over the privacy and security of that information. The telephone survey of 170 residents found more than two-thirds of people surveyed were willing to have their health information automatically stored in an HIE. Most respondents, however, wanted safeguards against unauthorized viewing of their information (86 percent). They also wanted to be able to see who has viewed their information (86 percent), to be able to stop electronic storage of their data (84 percent), to be able to stop all viewing (83 percent) and to be able to select which parts of their health information are shared (78 percent). Among the approximately one-third of patients who were uncomfortable with automatic inclusion of their health information in an electronic database for HIE, 78 percent wished to approve all information explicitly, and most preferred restricting information by clinician (83 percent), visit (81 percent), or information type (88 percent). The authors conclude that given the highly sensitive nature of health information and the consequences that can occur in the event of its disclosure, patient preferences around the storing and sharing of electronic health information should be considered when developing and implementing systems, standards and policies. They advocate for consent policies that allow consumers to control what, by whom and for how long their health information can be accessed.

Health Care Consumers' Preferences Around Health Information Exchange

By Rina V. Dhopeshwarkar, MPH, et al

Weill Cornell Medical College, New York, NY

Direct Mailing of Fecal Occult Blood Test Kits Improves Screening Rates Among Medically Underserved Patients

Direct mailing of fecal occult blood test kits to patients eligible for colorectal cancer screening appears to be efficacious for improving screening in historically underserved communities. A randomized control trial including 202 patients at a community health clinic in Chicago, Ill., found patients assigned to an outreach intervention consisting of the mailing of FOBT kits with follow-up telephone calls to initial nonresponders had a 30 percent screening rate, compared with a 5 percent screening rate among patients in the usual-care group. Although prior studies have shown the direct-to-patient mailing of FOBT kits can lead to higher colorectal cancer screening rates in predominantly white, middle-class or well-insured populations, this study adds to the existing literature by demonstrating that this outreach strategy can significantly improve screening rates even among economically disadvantaged patients from a wide range of racial, ethnic and cultural backgrounds. This finding is especially important given the marked disparities in colorectal screening among racial and ethnic minorities, individuals with lower income and educational attainment, the uninsured and individuals born outside the United States.

Program to Improve Colorectal Cancer Screening in a Low-Income, Racially Diverse Population: A Randomized Controlled Trial

By Muriel Jean-Jacques, MD, MA, et al

Northwestern University, Chicago, Ill.

Patterns of Psychological Distress and Recovery Following Stroke

Drawing from interviews with 23 recent stroke victims, researchers explore common disease trajectories, or longitudinal patterns of psychological distress and recovery, in the 12 months following stroke. They identify four distinct trajectories resilience, ongoing mood disturbance, emergent mood disturbance and recovery from mood disturbance. Recovery from mood disturbance, they note, was facilitated by gains in independence and self-esteem and by having an internal health locus of control. The authors conclude that identifying distinct trajectories of psychological morbidity may help primary care physicians develop appropriately timed interventions to promote better mental health among stroke patients.

Trajectories of Psychological Distress After Stroke

By Jennifer H. White, MMS, et al

Hunter Stroke Service, Australia

Development and Validation of a New Measure of Continuity of Care

Researchers describe the development and validation of an instrument to measure continuity of care from the patient's perspective. The measure, they conclude, reliably captures nine dimensions of continuity experienced by patients when they encounter multiple caregivers in various places. Though it builds on previous measures of continuity of care, this refined measure represents an important addition to existing tools by integrating different types of continuity that address the dimensions of information transfer, care plan and monitoring, support for self-management and team-work focused on coordination.

Validation of a Generic Measure of Continuity of Care: When Patients Encounter Several Clinicians

By Jeannie L. Haggerty, PhD, et al

McGill University, Quebec, Canada

Contact: Angela Sharma
American Academy of Family Physicians

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