Primary Care in the United States: Past, Present and Future.

Even though a well-functioning primary care system is widely acknowledged as critical to population health, the number of primary care physicians (PCPs) practicing in the United States has steadily declined, and PCPs are in short supply. The reasons are multiple and include inadequate income relative to other specialties, excessive administrative demands on PCPs and the lack of respect given to primary care specialties during medical school and residency. Advanced practice nurses can augment the services of primary care physicians but cannot substitute for them. To change this situation, we need action on several fronts. Medical schools should give preference to students who are more likely to enter the primary care specialties. The income gap between primary care and other specialties should be narrowed. The administrative load placed on PCPs, including cumbersome electronic medical records, must be lessened. Insurers, including Medicare and Medicaid, must provide the resources to allow primary care physicians to act as leaders of multidisciplinary teams.

In AF with recent ACS or PCI, apixaban improved 30-day outcomes vs. VKAs; aspirin effects varied vs. placebo.

SOURCE CITATION: Alexander JH, Wojdyla D, Vora AN, et al. Risk/benefit tradeoff of antithrombotic therapy in patients with atrial fibrillation early and late after an acute coronary syndrome or percutaneous coronary intervention: insights from AUGUSTUS. Circulation. 2020;141:1618-27. 32223444.

The American Health Care System Is Broken. Part 7: How Can We Fix It?

Previous articles have outlined the many problems that confront America in trying to humanely and efficiently deliver health care to our citizens.  First among these is that health care is unaffordable for too many. This final article describes how to expand coverage to all Americans and identifies many specific areas in which changes can be made to both improve care and lower costs.  There are many ways to reduce the cost of medications, to improve hospital care while lowering costs, to eliminate "surprise" medical bills, and to cut down fraud and waste.  The socioeconomic factors that contribute heavily to our poor health outcomes must be addressed.

America's Health Care System Is Broken: What Went Wrong and How We Can Fix It. Part 5: Malpractice, Fraud, Waste, and the EMR.

Although the exact sums can only be estimated, large amounts of money are wasted by the US health care system through fraud and by spending on tests, procedures, and treatments that are of no proven benefit. The adversarial fault-finding malpractice system siphons off large amounts of money from patients to lawyers and legal costs and is a deterrent to system improvement. While electronic records have the potential to improve care and lower costs through information sharing, their current implementation neither improves care nor lowers costs. If care is to be improved while costs are reduced, changes must be made in all these areas.

America's Health Care System Is Broken: What Went Wrong and How We Can Fix It. Part 6: Social Factors.

Although previous articles in the series have focused on the key players in our health care system, even larger factors that impact the cost and outcome of the nation's health lie in areas that are not traditionally thought of as "health care." Diet and exercise play a huge role in longevity and well-being. The best health care systems are unable to do much to lower deaths from firearms and motor vehicle crashes. Changing our focus from health care institutions to how to better support patients in the community will both lower cost and improve satisfaction. We need to learn how to better integrate patients' wishes into end-of-life care to provide more humanistic as well as less expensive care.

America's Health Care System is Broken: What Went Wrong and How We Can Fix It. Part 3: Hospitals and Doctors.

Thirty-two percent of US health care spending goes to hospital care, and 20% goes to physicians' charges. The cost of hospital care in the United States is 2-3 times greater than in most similar countries. A large part of the high cost is due to a very large administrative overhead. Both higher quality and lower cost would be achieved if complex procedures were done in fewer centers. Hospitals with a geographic or prestige monopoly receive higher payments than warranted. As physicians are increasingly employed by hospitals rather than independent, costs go up with no added benefit to patients. The United States has too many specialists and too few primary care physicians. Practice guidelines are slanted to favor expensive treatments, often with little solid evidence behind the recommendations.

America's Health Care System is Broken: What Went Wrong and How We Can Fix It. Part 4: The Pharmaceutical Industry.

As is true for most aspects of the US health care system, we pay much more for medications than do patients in any other country. Not only are new "breakthrough" products expensive, but existing products see price increases that regularly outstrip general inflation, making the pharmaceutical industry very profitable and resulting in many patients skipping or cutting the doses of such critical medicines as insulin. There is little relation between the effectiveness and the price of many medications. Drug firms like to cite the high cost of research and development but spend more on marketing than on research and development. The firms also spend large sums on lobbying and to influence medical thought leaders to keep their profits high. We are alone in spending billions of dollars on pharmacy benefit managers that add little value. With new gene-based therapies on the horizon, the price of therapeutics may be unsustainable.

America's Health Care System is Broken: What Went Wrong and How We Can Fix It. Part 2: Health Insurance.

Unlike most Western democracies, health insurance in the United States is provided by a haphazard mix of employer-based plans, Medicare for those over age 65 years or on social security disability or with chronic renal failure, Medicaid under varying state-dependent rules for some low-income recipients, and no insurance for tens of millions. Administrative costs, which include both the direct costs of the insurers and the indirect costs imposed on physicians and hospitals, make up nearly 25% of our bloated national health care expenditures. This high cost adds no proven value to health care outcomes. Our current system of covering health care expenditures is both inefficient and unfair. Changes must be made.

America's Health Care System Is Broken: What Went Wrong and How We Can Fix It. Introduction to the Series.

Over the last half-century, medical science has dramatically improved throughout the world. Although costs have risen in all western countries as new technologies have been widely adopted, costs in the United States have risen much more than they have in any other country. Despite using fewer resources (eg, numbers of physicians and nurses, hospital beds) than do peer countries, per-capita spending on health care in the United States is double that in similar countries. The major driving force behind this difference is that we in the United States pay much more for the same products and services. There is no evidence that this increased spending gives better outcomes. Neither the general public nor doctors are happy with our current health care system. Subsequent articles will discuss the components of our system and how they are failing and how they can be improved.

Healthcare information technology and economics.

At the 2011 American College of Medical Informatics (ACMI) Winter Symposium we studied the overlap between health IT and economics and what leading healthcare delivery organizations are achieving today using IT that might offer paths for the nation to follow for using health IT in healthcare reform. We recognized that health IT by itself can improve health value, but its main contribution to health value may be that it can make possible new care delivery models to achieve much larger value. Health IT is a critically important enabler to fundamental healthcare system changes that may be a way out of our current, severe problem of rising costs and national deficit. We review the current state of healthcare costs, federal health IT stimulus programs, and experiences of several leading organizations, and offer a model for how health IT fits into our health economic future.

Presence of key findings in the medical record prior to a documented high-risk diagnosis.

BACKGROUND: Failure or delay in diagnosis is a common preventable source of error. The authors sought to determine the frequency with which high-information clinical findings (HIFs) suggestive of a high-risk diagnosis (HRD) appear in the medical record before HRD documentation. METHODS: A knowledge base from a diagnostic decision support system was used to identify HIFs for selected HRDs: lumbar disc disease, myocardial infarction, appendicitis, and colon, breast, lung, ovarian and bladder carcinomas. Two physicians reviewed at least 20 patient records retrieved from a research patient data registry for each of these eight HRDs and for age- and gender-compatible controls. Records were searched for HIFs in visit notes that were created before the HRD was established in the electronic record and in general medical visit notes for controls. RESULTS: 25% of records reviewed (61/243) contained HIFs in notes before the HRD was established. The mean duration between HIFs first occurring in the record and time of diagnosis ranged from 19 days for breast cancer to 2 years for bladder cancer. In three of the eight HRDs, HIFs were much less likely in control patients without the HRD. CONCLUSIONS: In many records of patients with an HRD, HIFs were present before the HRD was established. Reasons for delay include non-compliance with recommended follow-up, unusual presentation of a disease, and system errors (eg, lack of laboratory follow-up). The presence of HIFs in clinical records suggests a potential role for the integration of diagnostic decision support into the clinical workflow to provide reminder alerts to improve the diagnostic focus.

Impact of a computer-based diagnostic decision support tool on the differential diagnoses of medicine residents.

BACKGROUND: Computer-based medical diagnostic decision support systems have been used for decades, initially as stand-alone applications. More recent versions have been tested for their effectiveness in enhancing the diagnostic ability of clinicians. OBJECTIVE: To determine if viewing a rank-ordered list of diagnostic possibilities from a medical diagnostic decision support system improves residents' differential diagnoses or management plans. METHOD: Twenty first-year internal medicine residents at Massachusetts General Hospital viewed 3 deidentified case descriptions of real patients. All residents completed a web-based questionnaire, entering the differential diagnosis and management plan before and after seeing the diagnostic decision support system's suggested list of diseases. In all 3 exercises, the actual case diagnosis was first on the system's list. Each resident served as his or her own control (pretest/posttest). RESULTS: For all 3 cases, a substantial percentage of residents changed their primary considered diagnosis after reviewing the system's suggested diagnoses, and a number of residents who had not initially listed a "further action" (laboratory test, imaging study, or referral) added or changed their management options after using the system. Many residents (20% to 65% depending on the case) improved their differential diagnosis from before to after viewing the system's suggestions. The average time to complete all 3 cases was 15.4 minutes. Most residents thought that viewing the medical diagnostic decision support system's list of suggestions was helpful. CONCLUSION: Viewing a rank-ordered list of diagnostic possibilities from a diagnostic decision support tool had a significant beneficial effect on the quality of first-year medicine residents' differential diagnoses and management plans.