Public Release: 

May/June 2015 Annals of Family Medicine tip sheet

American Academy of Family Physicians

More Comprehensive Care Among Family Physicians Associated with Lower Costs and Fewer Hospitalizations

Comprehensiveness - offering services across a broad range of diseases, procedures, and settings to a broad range of patients - is lauded as one of the five core virtues of primary care, but its effect on health care utilization and costs is unclear. Given the considerable advances in health care technology, our aging and more insured population, and significant variation and decreasing scope of practice by family physicians, researchers examine whether comprehensiveness has a positive effect on costs. Studying the relationship between individual family physicians' comprehensiveness and hospitalization rates and total costs among their Medicare beneficiaries, researchers found more comprehensive scope of practice is associated with significantly lower Medicare expenditures per beneficiary and fewer hospitalizations. Specifically, analysis of claims data for a large, nationally representative sample of 3,652 family physicians and their 555,165 patients showed that patients of family physicians who reported performing and who billed for a broader range of services had 10 to 15 percent lower costs when compared to the least comprehensive physicians in the sample. These findings, the authors conclude, confirm that comprehensiveness in family medicine is both measurable and important. Absent this important evidence, the authors warn, there is real risk of continued, unresisted erosion of family medicine's commitment to comprehensive care in the name of daily patient volume and efficiency. These findings, they assert, should encourage policy makers to consider training and payment policies that support more robust and comprehensive practices as one means of bending the cost curve and achieving the nation's Triple Aim. They call for further exploration of the measurement of comprehensiveness and its relationship to cost, access and quality of care.

In an accompanying editorial, Kevin Grumbach, MD, chair of the Department of Family and Community Medicine at the University of California, San Francisco, interprets the study findings and emphasizes why this new evidence should matter to patients, employers, government, and others seeking better value for the health care dollar. With the research by Bazemore and colleagues demonstrating that the comprehensiveness of primary care matters in ways that are important to the public and health system, he calls for deeper investigation to identify which specific components of comprehensiveness most strongly impact the association with lower costs. He concludes that the study by Bazemore and colleagues serves as an important call to health policymakers to support the reforms needed to promote the comprehensive practice of primary care, and to family physicians to objectively assess how comprehensiveness of primary care advances society's aims of better health and better patient experience in addition to promoting more affordable costs.

More Comprehensive Care Among Family Physicians is Associated with Lower Costs and Fewer Hospitalizations

By Andrew Bazemore, MD, MPH, et al The Robert Graham Center, Washington, DC

To Be or Not to Be Comprehensive

By Kevin Grumbach, MD

University of California, San Francisco

Adverse Impact of UK Policy Reforms on Short-Stay Hospital Admissions for Children

In England, primary care reforms heavily focused on improving chronic disease management in adults may have had negative unintended consequences on children with primary care-sensitive conditions. Assessing the impact of policy reforms implemented in 2004 that reduced the availability of primary care to children, researchers found the introduction of reforms coincided with an increase in short-stay admission rates for children with primary care-sensitive chronic conditions and with more children being admitted through emergency departments. Specifically, they found that between April 2000 and March 2013, there were 7.8 million unplanned hospital admissions for children younger than 15 years. More than one-half (4,144,729 of 7,831,633) were short-stay admissions for potentially avoidable infections and chronic conditions. The primary care policy reforms implemented in April 2004 were associated with an 8 percent increase in short-stay admission rates for chronic conditions, equivalent to 8,500 additional admissions, above the 3 percent annual increasing trend. These increases, the authors note, were accompanied by a decrease in admissions of children referred by a primary care physician. Notably, the policy reforms were not associated with an increase in short-stay admission rates for infectious illness, which were increasing by 5 percent annually before April 2004. The authors suggest that the more steady increase in admission rates for primary care-sensitive infections may be attributed to lowered thresholds for hospital admission. They write that while they cannot infer causation from the findings, the magnitude of an 11 percent increase in short-stay admissions for chronic disease lends weight to speculation that such admissions may increase when primary care provision is withdrawn. That short-stay admission rates among children with chronic conditions changed immediately in 2004 and are now surpassing other causes of admission in older children, they assert, is particularly concerning. They contend that this development may indicate an adverse impact of financial incentive schemes focusing on chronic conditions in adults.

Impact of UK Primary Care Policy Reforms on Short-Stay Unplanned Hospital Admissions for Children With Primary Care-Sensitive Conditions

By Elizabeth Cecil, MSc, et al

Imperial College London, England

Repeated Depression Screening During First Postpartum Year Increases Number of High Risk Patients Identified

With previous research suggesting later onset postpartum depression, researchers evaluated the benefit of repeated PPD screening during the first postpartum year and found 14 percent of new mothers who initially screen negative for postpartum depression end up developing depressive symptoms during the course of the first postpartum year. Researchers screened 1,801 women for PPD at four to 12 weeks postpartum and again at six and at 12 months postpartum and found that at six months, 134 (11 percent) of the 1,235 women who did not have elevated depression screening scores at baseline had elevated scores at the six month screening. Further, at 12 months, 59 (7 percent) of the 969 women who previously did not have elevated scores did. Together, the six- and 12-month repeated screenings identified 193 women at high risk of depression, representing 14 percent of the 1,432 women whose screening results were negative for PPD at baseline. The authors assert these findings affirm that rescreening can identify an additional group of women appropriate for careful clinical evaluation of PPD and who may be candidates for depression therapy. They call for future research to understand the impact of repeated PPD screening on patient outcomes.

Repeated Depression Screening During the First Postpartum Year

By Barbara P. Yawn, MD, MSc, et al

Olmsted Medical Center, Rochester, Minnesota

Women With False Positive Mammograms Have Similar Psychosocial Consequences Regardless of the Invasiveness of Diagnostic Follow-up Procedures

Contrary to previous research suggesting that increasingly invasive diagnostic procedures after false-positive mammography are associated with poorer negative psychosocial outcomes, researchers in Denmark found regardless of the nature of subsequent diagnostic tests, women with false-positive mammography have psychosocial consequences that are poorer than those of women with normal results and better than those of women with breast cancer. Researchers analyzed data on 454 women with abnormal screening mammography and 908 matched control women with normal results. Among the 252 women in the group with false-positive mammography, psychosocial outcomes were similar for those managed invasively (with a biopsy) and those managed noninvasively (with only additional imaging) during 36 months follow up. In fact, the authors note that the best estimate for the difference in psychosocial consequences between women managed invasively and noninvasively was close to zero. The authors conclude that interventions to limit the psychosocial harm of mammography screening should focus on reducing the total number of false-positive tests because these findings demonstrate that women who require only clinical examination and additional imaging experience the same degree of distress as women who undergo invasive procedures.

Diagnostic Invasiveness and Psychosocial Outcomes of False-Positive Mammography

By Buno Heleno, PhD, et al

University of Copenhagen, Denmark

Recreational Weekend-Only Drug Use Often Leads to Weekday Use

Weekend-only drug use frequently progresses into daily use and warrants continued monitoring in primary care. Researchers examined the pattern of drug use over six months for 483 adult primary care patients who presented at Boston Medical Center for a primary care visit and screened positive for drug use. At baseline, 52 patients in the sample (11 percent) reported using drugs only on weekends while 431 (89 percent) reported using drugs at other times as well. Of those reporting weekend-only use at baseline, only 10 (19 percent) retained the weekend-only pattern six months later, whereas 28 (54 percent) started using drugs on other days of the week and 14 (27 percent) reported abstinence. These findings, the authors conclude, support the importance of periodic monitoring of "recreational" drug use.

Recreational Drug Use Among Primary Care Patients: Implications of a Positive Self-Report

By Judith Bernstein, RNC, PhD, et al

Boston University School of Public Health, Massachusetts

Communication Practices That Can Reduce Antibiotic Prescribing for Acute Respiratory Tract Infections in Children and Improve Visit Ratings

In a study that could inform efforts to reduce antibiotic prescribing for viral respiratory tract infections, researchers found that when pediatric providers suggest actions parents can take to reduce their child's symptoms (positive treatment recommendations) and offer explanations of the inappropriateness of antibiotics for their child's infection (negative treatment recommendations), they are less likely to prescribe antibiotics and still maintain a positive care experience for patients. Analyzing surveys from patients and physicians after 1,284 pediatric visits for acute respiratory tract infection symptoms, researchers found that providing positive treatment recommendations was associated with decreased risk of antibiotic prescribing whether done alone or in combination with negative treatment recommendations (adjusted risk ratio 0.48, 95 percent confidence interval, 0.24-0.95 and adjusted risk ratio 0.15, 95 percent confidence interval, 0.06-0.40, respectively). Parents receiving combined positive and negative treatment recommendations were more likely to give the highest possible visit rating (adjusted risk ratio 1.16, 95 percent confidence interval, 1.01-1.34). The authors conclude that the combined use of positive and negative treatment recommendations may reduce the risk of antibiotic prescribing for children with viral infections and at the same time improve visit ratings. With the growing threat of antibiotic resistance at the community and individual level, they assert, these communication techniques may assist frontline providers in helping to address this pervasive public health problem.

Communication Practices and Antibiotic Use for Acute Respiratory Tract Infections in Children

By Rita Mangione-Smith, MD, MPH, et al

Seattle Children's Research Institute, Washington

Clinicians Report on Working Under a Team-Level Quality Incentive Program; Majority Advocate a Hybrid Model That Recognizes Individual and Team Performance

Researchers examined clinicians' experiences working under a team-based quality-focused compensation model, in which 40 percent of compensation is based on clinic-level quality performance. They found that after almost two and half years of working under the model, only a small minority (15 percent) would base quality incentives entirely at the team level -- effectively rejecting the incentive approach under which they were working. In-depth interviews with 48 clinicians and an online survey of 150 clinicians employed by Fairview Health Services, a large nonprofit health care delivery system in Minnesota with 44 primary care clinics, revealed both strengths and weakness of the clinic-level quality incentive. Key benefits of team-level incentives noted included clinicians' improved quality performance as it related to feeling a sense of responsibility to the team, greater collaboration with colleagues, and less patient "dumping" or shifting patients with poor outcomes to other clinicians. However, many clinicians indicated the team-level incentive also created substantial frustration principally based upon clinicians feeling they had little control over their own compensation and colleagues riding the coattails of higher performers. While only15 percent of those surveyed would base quality incentives entirely at the team level, fewer still (7 percent) were interested in basing quality incentives exclusively at the individual level, fearing increases in patient dumping and decreased congeniality. Interestingly, almost three-quarters of clinicians (73 percent) indicated that a hybrid model, mixing both individual-level and team-level incentives would be ideal -- because of the potential to maintain the strengths of each model while mitigating their weaknesses. The researchers conclude these findings highlight the complexity of designing financial incentive programs. They call for future research to test whether hybrid incentives that mix group and individual incentives can maintain some of the best elements of each design while mitigating the negative impacts.

Working Under a Clinic-Level Quality Incentive: Primary Care Clinicians' Perceptions

By Jessica Greene, PhD, MPH, et al

The George Washington University, Washington, DC

Even Among Practices With a Strong Commitment to the Medical Home Model, Most Still Depend on Non-Health Information Technology Methods to Manage Care Coordination

In a survey of recognized patient-centered medical home practices participating in the Centers for Medicare and Medicaid Services "Meaningful Use" Electronic Health Record Incentive Program, researchers found that even among practices having a strong commitment to the medical home model, the use of health information technology to support care coordination objectives is not consistent and often not aligned with clinicians' priorities. Specifically, they found that of the 350 practices surveyed, 78 percent viewed timely notification of hospital discharges as very important, yet only 49 percent used heath IT systems to accomplish this task. Among the practices surveyed, the activity most frequently supported by health IT was providing clinical summaries to patients (77 percent of practices); however, only 48 percent considered this activity very important. Fewer than one-half of practices routinely used computerized systems to identify patients seen in emergency department or hospital settings or to send a comprehensive care summary to other providers. Overall, 21 percent of clinicians reported that their practices performed all of the 10 care coordination activities evaluated and on average conducted six of the 10 activities using EHR/health IT systems. The authors found that having a stronger capacity to change and having a non-clinician responsible for care coordination was positively associated with greater use of health IT to support care coordination activities. While the use of health IT for care coordination in this study was higher than that seen in earlier national physician surveys, the authors conclude that these findings demonstrate that many practices will need financial and technical assistance to support care coordination objectives.

Health IT-Enabled Care Coordination: A National Survey of Patient-Centered Medical Home Clinicians

By Suzanne Morton, MPH, MBA, et al

National Committee for Quality Assurance, Washington, DC

Impact of New Patient-Centered Care Models on Quality and Efficiency Pose Challenge for Physicians Attempting to Focus and Prioritize Improvement Efforts

Analyzing data and experience from UnitedHealthcare's patient-centered medical home and performance transparency programs, involving nearly 250,000 U.S. physicians practicing in 41 states and covering 21 medical specialties, researchers report positive effects of PCMH on clinical quality and medical costs over time. However, they also report that while medical home recognition is positively associated with meeting quality benchmarks, it is negatively associated with efficiency parameters. With these findings in mind, the authors tackle the question of how practicing physicians should focus and prioritize their improvement efforts. Should practices spend time and energy focusing on structural measures and process changes such as those embodied in the patient-centered medical home recognition, or focus on improving quality and efficiency measures from private payers that could affect their fee schedules, degree of participation in narrow networks or patient volumes? Or, should they focus on making sure they report and improve on measures from the Centers for Medicare and Medicaid Services to avoid reductions in fees from the Medicare fee-for-service program? They advise physicians to incorporate multiple perspectives and apply triangulation to develop the best course of action in understanding and acting on the data from measurement programs. They call on payers and those who are doing measurement to work to better align measurement approaches to achieve greater consistency.

Measuring Physician Quality and Efficiency in an Era of Practice Transformation: PCMH as a Case Study

By Lewis G. Sandy, MD, et al

UnitedHealth Group, Minnetonka, Minnesota

Frontline Perspectives Shed Light on the Unintended Consequences of the Myriad Certification Initiatives Facing Family Physicians

Complementary essays by family physicians with highly successful practices provide an on-the-ground perspective on the multitude of quality improvement, delivery reform, measurement and incentive programs confronting today's family physicians.

In the first article, physicians from two small, innovative primary care practices assert that, even having achieved National Committee for Quality Assurance Level 3 recognition as patient-centered medical homes, they find that the recognition process mismatches form and function, is costly and wasteful and succeeds more in documentation of policies than in supporting improved outcomes in practices. The authors describe the actual process of using the tool, assess its utility using a framework based on patient experience of care, costs and population health, and conclude that it should be discontinued.

In a second article, a family physician who leads a small practice in rural western North Carolina reflects on how he is considering walking away from the time-intensive PCMH recognition process even though he believes in the practice transformation it is intended to guide and may suffer financial hardship as a result. Despite his practice having been at the cutting edge of reforms and certifications, he writes that he now finds the plethora of processes takes too much away from his ability to care for patients, improve his practice and engage with patients in a meaningful way. He contends that NCQA must work to improve the recognition processes in ways that relieve the burden of work placed on practices that have active quality improvement programs.

The Dissenter's Viewpoint: There Has to Be a Better Way to Measure a Medical Home

By Jean Antonnuci, MD and Lynn Ho, MD

Farmington, Maine, and North Kingstown, Rhode Island

When Practice Transformation Impedes Practice Improvement

By Edward Bujold, MD, FAAFP, Granite Falls, NC

Behavioral Health Screening Program Improves Identification and Diagnosis of Depression and Substance Abuse in Community Health Clinic

Researchers examined the efficacy of the Screening, Brief Intervention, and Referral to Treatment (SBIRT) program, aimed at increasing the rates of diagnosis of depression and substance abuse and referrals of patients, and they found that the program doubles the rates of diagnosis and results in large increases in rates of referral when implemented in a community health center. Comparing rates of diagnosis and referral at a control and intervention clinic, researchers found the intervention group was twice as likely to have depression and substance abuse diagnosed compared with the control group (25 percent versus 11 percent). Referral rates for the study group were more likely to occur (12 percent) compared with referral rates for the control group (1 percent). The author concludes that SBIRT shows promise for more timely intervention, referral and treatment of depression and substance abuse, major social and public health concerns, which are currently underdiagnosed in primary care settings.

SBIRT as a Vital Sign for Behavioral Health Identification, Diagnosis, and Referral in Community Health Care

By Ronald Dwinnells, MD, MBA, CPE, FAAP

Ohio North East Health Systems, Inc.

Youngstown, Ohio

Understanding Clinician-Patient Interactions as Interacting Presentations of Self

A family physician provides a framework for understanding clinician-patient interactions as interacting presentations of self, related to meaning, agency, and organism. Using the mnemonic ABCDE to help distinguish and remember the five proposed presentations of self, he describes key dimensions of each and suggests how physicians can reflect on these dimensions in order to find equilibrium in their interactions with patients. He explains how balancing these individual identities can reduce relational challenges and enhance communication effectiveness.

ABCDE in Clinical Encounters: Presentations of Self in Doctor-Patient Communication

By William Ventres, MD, MA

University of El Salvador, San Salvador

A Physician Reflects on the Limits of his Ability to Bring About Meaningful Change In The Life Of An Impassive Patient

A family physician relates an encounter with a patient who wants to quit smoking, lose weight and control her diabetes, yet who deflects his recommendations when he inquires about her body and behaviors. He explains that physicians' efforts to understand patients' stories and deepen the conversation do not always guarantee change, and he reflects on how the experience reminds him why patience, humility and faith are core values of the primary care physician.

One Cold Autumn Day

By Peter de Schweinitz, MD, MSPH, et al

Chief Andrew Isaac Health Center, Fairbanks, Alaska

Reflection: A Smile Saying Thank You

A family physician reflects on an experience as a fourth-year medical resident at an impoverished outreach clinic in Beirut when a young patient's unique thank you answered her questions about the meaning of her profession.

Smiling Toothless

By Maria Sami Ramia, MD

American University of Beirut Medical Center, Lebanon

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Annals of Family Medicine is a peer-reviewed, indexed research journal that provides a cross-disciplinary forum for new, evidence-based information affecting the primary care disciplines. Launched in May 2003, Annals is sponsored by seven family medical organizations, including the American Academy of Family Physicians, the American Board of Family Medicine, the Society of Teachers of Family Medicine, the Association of Departments of Family Medicine, the Association of Family Medicine Residency Directors, the North American Primary Care Research Group, and the College of Family Physicians of Canada. Annals is published six times each year and contains original research from the clinical, biomedical, social and health services areas, as well as contributions on methodology and theory, selected reviews, essays and editorials. Complete editorial content and interactive discussion groups for each published article can be accessed free of charge on the journal's website, http://www.annfammed.org.

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