Primary Care Physician Perspectives on the Influence of Patient Values, Health Priorities, and Preferences on Clinical Decision-Making for Complex Patients with Multimorbidity: A Qualitative Study.

Introduction: The prevalence of patients with multimorbidity (ie, multiple chronic conditions) is increasing. Clinical decision-making guided by patients' values, health priorities and goals, and treatment preferences is particularly important in the context of interacting diseases and psychosocial needs. Physicians face challenges incorporating patient perspectives into care plans. We examined primary care physician (PCP) views on the influence of patients' values, health priorities and goals, and preferences on clinical decisions for patients with multimorbidity and increased psychosocial complexity. Methods: We conducted semi-structured telephone interviews with 23 PCPs within patient-centered medical home teams in a nationally integrated health system in the United States between May and July 2020. Data were analyzed via thematic analysis with deductive and inductive coding. Results: Three major themes emerged: 1. Patient personal values were rarely explicitly discussed in routine clinical encounters but informed more commonly discussed concepts of patient priorities, goals, and preferences; 2. Patient values, health priorities and goals, and preferences were sources of divergent views about care plans between healthcare teams, patients, and families; 3. Physicians used explicit strategies to communicate and negotiate about patient values, health priorities and goals, and preferences when developing care plans, including trust-building; devoting extra effort to individualizing care; connecting patient values to healthcare recommendations; deliberate elicitation and acknowledgement of patient concerns; providing "space" for patient perspectives; incorporating family into care planning; pairing physician to patient priorities; and collaborative teamwork. Conclusion: Primary care physicians perceive patient values, health priorities and goals, and preferences as influential during clinical decision-making for complex patients with multimorbidity. Participants used concrete strategies to negotiate alignment of these aspects when physician-patient divergence occurred. While rarely discussed directly in clinical encounters, personal values affected patient health priorities, goals, and preferences during care planning, suggesting a clinical role for more deliberate elicitation and discussion of patient values for this population.

Association of Integrated Mental Health Services with Physical Health Quality Among VA Primary Care Patients.

BACKGROUND: Integrated care for comorbid depression and chronic medical disease improved physical and mental health outcomes in randomized controlled trials. The Veterans Health Administration (VA) implemented Primary Care-Mental Health Integration (PC-MHI) across all primary care clinics nationally to increase access to mental/behavioral health treatment, alongside physical health management. OBJECTIVE: To examine whether widespread, pragmatic PC-MHI implementation was associated with improved care quality for chronic medical diseases. DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study included 828,050 primary care patients with at least one quality metric among 396 VA clinics providing PC-MHI services between October 2013 and September 2016. MAIN MEASURE(S): For outcome measures, chart abstractors rated whether diabetes and cardiovascular quality metrics were met for patients at each clinic as part of VA's established quality reporting program. The explanatory variable was the proportion of primary care patients seen by integrated mental health specialists in each clinic annually. Multilevel logistic regression models examined associations between clinic PC-MHI proportion and patient-level quality metrics, adjusting for regional, patient, and time-level effects and clinic and patient characteristics. KEY RESULTS: Median proportion of patients seen in PC-MHI per clinic was 6.4% (IQR=4.7-8.7%). Nineteen percent of patients with diabetes had poor glycemic control (hemoglobin A1c >9%). Five percent had severely elevated blood pressure (>160/100 mmHg). Each two-fold increase in clinic PC-MHI proportion was associated with 2% lower adjusted odds of poor glycemic control (95% CI=0.96-0.99; p=0.046) in diabetes. While there was no association with quality for patients diagnosed with hypertension, patients without diagnosed hypertension had 5% (CI=0.92-0.99; p=0.046) lower adjusted odds of having elevated blood pressures. CONCLUSIONS AND RELEVANCE: Primary care clinics where integrated mental health care reached a greater proportion of patients achieved modest albeit statistically significant gains in key chronic care quality metrics, providing optimism about the expected effects of large-scale PC-MHI implementation on physical health.

Factors affecting primary care physician decision-making for patients with complex multimorbidity: a qualitative interview study.

BACKGROUND: Patients with multiple chronic conditions (multimorbidity) and additional psychosocial complexity are at higher risk of adverse outcomes. Establishing treatment or care plans for these patients must account for their disease interactions, finite self-management abilities, and even conflicting treatment recommendations from clinical practice guidelines. Despite existing insight into how primary care physicians (PCPs) approach care decisions for their patients in general, less is known about how PCPs make care planning decisions for more complex populations particularly within a medical home setting. We therefore sought to describe factors affecting physician decision-making when care planning for complex patients with multimorbidity within the team-based, patient-centered medical home setting in the integrated healthcare system of the U.S. Department of Veterans Affairs, the Veterans Health Administration (VHA). METHODS: This was a qualitative study involving semi-structured telephone interviews with PCPs working > 40% time in VHA clinics. Interviews were conducted from April to July, 2020. Content was analyzed with deductive and inductive thematic analysis. RESULTS: 23 physicians participated in interviews; most were MDs (n = 21) and worked in hospital-affiliated clinics (n = 14) across all regions of the VHA's national clinic network. We found internal, external, and relationship-based factors, with developed subthemes describing factors affecting decision-making for complex patients with multimorbidity. Physicians described tailoring decisions to individual patients; making decisions in keeping with an underlying internal style or habit; working towards an overarching goal for care; considering impacts from patient access and resources on care plans; deciding within boundaries provided by organizational structures; collaborating on care plans with their care team; and impacts on decisions from their own emotions and relationship with patient. CONCLUSIONS: PCPs described internal, external, and relationship-based factors that affected their care planning for high-risk and complex patients with multimorbidity in the VHA. Findings offer useful strategies employed by physicians to effectively conduct care planning for complex patients in a medical home setting, such as delegation of follow-up within multidisciplinary care teams, optimizing visit time vs frequency, and deliberate investment in patient-centered relationship building to gain buy-in to care plans.

Identifying and Prioritizing Workplace Climate Predictors of Burnout Among VHA Primary Care Physicians.

OBJECTIVE: Burnout, or job-related stress, affects more than half of all US physicians, with primary care physicians (PCPs) experiencing some of the highest rates in medicine. Our study analyzes national survey data to identify and prioritize workplace climate predictors of burnout among PCPs within a large integrated health system. DESIGN: Observational study of annual survey data from the Veterans Health Administration (VHA) All Employee Survey (AES) for 2013-2017. AES response rate ranged from 56 to 60% during the study period. Independent and dependent variables were measured from separate random samples. In total, 8,456 individual-level responses among PCPs at 110 VHA practice sites were aggregated at the facility level by reporting year. We used the semi-automated LASSO procedure to identify workplace climate measures that were more influential in predicting burnout and assessed relative importance using the Shapely value decomposition. PARTICIPANTS: VHA employees that self-identify as PCPs. MAIN MEASURES: Dependent variables included two dichotomous measures of burnout: emotional exhaustion and depersonalization. Independent measures included 30 survey measures related to dimensions of workplace climate (e.g., workload, leadership, satisfaction). RESULTS: We identified seven influential workplace climate predictors of emotional exhaustion and nine predictors of depersonalization. With few exceptions, higher agreement/satisfaction scores for predictors were associated with a lower likelihood of burnout. The majority of explained variation in emotional exhaustion was attributable to perceptions of workload (32.6%), organization satisfaction (28.2%), and organization support (19.4%). The majority of explained variation in depersonalization was attributable to workload (25.3%), organization satisfaction (22.9%), and connection to VHA mission (20.7%). CONCLUSION: Identifying the relative importance of workplace climate is important for the allocation of health organization resources to mitigate and prevent burnout within the PCP workplace. In a context of limited resources, efforts to reduce perceived workload and improve organization satisfaction may represent the biggest leverage points for health organizations to address physician burnout.

The Primary Care Analytics Team: Integrating research and clinical care within the Veterans Health Administration Office of Primary Care.

By designing and evaluating health system improvements and providing evidence to clinical decision-makers, embedded researchers are a critical part of a Learning Health System (LHS). In this article, we describe the evolution and mission of the Primary Care Analytics Team (PCAT), an integrated research team within the Veterans Health Administration Office of Primary Care. We discuss challenges and strategies for success in working with clinical operations partners and provide recommendations for other Learning Health Systems units embedded in large integrated health care organizations.

Use of General Primary Care, Specialized Primary Care, and Other Veterans Affairs Services Among High-Risk Veterans.

Importance: Integrated health care systems increasingly focus on improving outcomes among patients at high risk for hospitalization. Examining patterns of where patients obtain care could give health care systems insight into how to develop approaches for high-risk patient care; however, such information is rarely described. Objective: To assess use of general and specialized primary care, medical specialty, and mental health services among patients at high risk of hospitalization in the Veterans Health Administration (VHA). Design, Setting, and Participants: This national, population-based, retrospective cross-sectional study included all veterans enrolled in any type of VHA primary care service as of September 30, 2015. Data analysis was performed from April 1, 2016, to January 1, 2019. Exposures: Risk of hospitalization and assignment to general vs specialized primary care. Main Outcome and Measures: High-risk veterans were defined as those who had the 5% highest risk of near-term hospitalization based on a validated risk prediction model; all others were considered low risk. Health care service use was measured by the number of encounters in general primary care, specialized primary care, medical specialty, mental health, emergency department, and add-on intensive management services (eg, telehealth and palliative care). Results: The study assessed 4 309 192 veterans (mean [SD] age, 62.6 [16.0] years; 93% male). Male veterans (93%; odds ratio [OR], 1.11; 95% CI, 1.10-1.13), unmarried veterans (63%; OR, 2.30; 95% CI, 2.32-2.35), those older than 45 years (94%; 45-65 years of age: OR, 3.49 [95% CI, 3.44-3.54]; 66-75 years of age: OR, 3.04 [95% CI, 3.00-3.09]; and >75 years of age: OR, 2.42 [95% CI, 2.38-2.46]), black veterans (23%; OR, 1.63; 95% CI, 1.61-1.64), and those with medical comorbidities (asthma or chronic obstructive pulmonary disease: 33%; OR, 4.03 [95% CI, 4.00-4.06]; schizophrenia: 4%; OR, 5.14 [95% CI, 5.05-5.22]; depression: 42%; OR, 3.10 [95% CI, 3.08-3.13]; and alcohol abuse: 20%; OR, 4.54 [95% CI, 4.50-4.59]) were more likely to be high risk (n = 351 012). Most (308 433 [88%]) high-risk veterans were assigned to general primary care; the remaining 12% (42 579 of 363 561) were assigned to specialized primary care (eg, women's health and homelessness). High-risk patients assigned to general primary care had more frequent primary care visits (mean [SD], 6.9 [6.5] per year) than those assigned to specialized primary care (mean [SD], 6.3 [7.3] per year; P < .001). They also had more medical specialty care visits (mean [SD], 4.4 [5.9] vs 3.7 [5.4] per year; P < .001) and fewer mental health visits (mean [SD], 9.0 [21.6] vs 11.3 [23.9] per year; P < .001). Use of intensive supplementary outpatient services was low overall. Conclusions and Relevance: The findings suggest that, in integrated health care systems, approaches to support high-risk patient care should be embedded within general primary care and mental health care if they are to improve outcomes for high-risk patient populations.

Midlife mortality in White non-Hispanic male veterans enrolled in Department of Veterans Affairs primary care, 2003-2014.

BACKGROUND: After years of decline in mortality rates in the United States, there have been increases in mortality rates in White non-Hispanic Americans ages 45-54, due to increases in deaths from suicide, poisoning, and alcoholic liver disease. OBJECTIVES: To determine whether White non-Hispanic middle age male Veterans enrolled in Department of Veterans Affairs (VA) primary care had increased mortality, as found in the general population. RESEARCH DESIGN: Repeated cross-sectional analysis over 12 years to describe trends in death rates for men across 3 race/ethnicity groups (White non-Hispanic, Black non-Hispanic, Hispanic) and 2 age groups (45-54, 55-64) for the Veteran and general US male populations. SUBJECTS: 60 million patient-years for Veterans enrolled in VA primary care from 2003 to 2014 and 1.8 million who died during the study period. MEASURES: All-cause and cause specific death rates for alcoholic liver disease, poisoning, and suicide. RESULTS: For White non-Hispanic male Veterans ages 55-64, the increase in all-cause mortality from 2003 to 2014 (+309 deaths/100,000) was accompanied by significant changes in deaths due to poisoning (+30/100,000), alcoholic liver disease (+23/100,000), and suicide (+17/100,000). For US men ages 55-64, all-cause mortality decreased slightly from 2003-2014 (-22 deaths/100,000). However, there were increases in death rates due to poisoning (+17/100,000), alcoholic liver disease (+14/100,000) and suicide (+11/100,000). CONCLUSIONS: These disturbing findings for White non-Hispanic Veteran men ages 55-64 suggest the critical importance of suicide prevention programs as well as the importance of high quality integrated health care for both Veteran and non-Veteran men.

Integrating social and behavioral determinants of health into patient care and population health at Veterans Health Administration: a conceptual framework and an assessment of available individual and population level data sources and evidence-based measurements.

The premise of this project was that social and behavioral determinants of health (SBDH) affect the use of healthcare services and outcomes for patients in an integrated healthcare system such as the Veterans Health Administration (VHA), and thus individual patient level socio-behavioral factors in addition to the neighborhood characteristics and geographically linked factors could add information beyond medical factors mostly considered in clinical decision making, patient care, and population health. To help VHA better address SBDH risk factors for the veterans it cares for within its primary care clinics, we proposed a conceptual and analytic framework, a set of evidence-based measures, and their data source. The framework and recommended SBDH metrics can provide a road map for other primary care-centric healthcare organizations wishing to use health analytic tools to better understand how SBDH affect health outcomes.

Comparing Patient-Centered Medical Home Implementation in Urban and Rural VHA Clinics: Results From the Patient Aligned Care Team Initiative.

Rural Veterans Health Administration (VHA) primary care clinics are smaller, have fewer staff, and serve more rural patients compared with urban VHA primary care clinics. This may lead to different challenges to implementation of the Patient-Centered Medical Home (PCMH) model, the Patient Aligned Care Team, in the VHAs' large integrated health system. In this cross-sectional observational study of 905 VHA primary clinics in the United States and Puerto Rico, we found overall PCMH implementation was greater in rural compared to urban primary care clinics. Urban-rural differences in PCMH implementation may largely be related to clinic organizational factors.

Patient-Centered Medical Home Implementation in the Veterans Health Administration and Primary Care Use: Differences by Patient Comorbidity Burden.

BACKGROUND: The patient-centered medical home (PCMH) model has several components to improve care for patients with high comorbidity, including greater access to face-to-face primary care. OBJECTIVE: We examined whether high-comorbidity patients had larger increases in primary care provider (PCP) visits attributable to PCMH implementation in a large integrated health system relative to other patients enrolled in primary care. DESIGN, SUBJECTS AND MAIN MEASURES: This longitudinal study examined a 1 % random sample of 9.3 million patients enrolled in the Veterans Health Administration (VHA) at any time between 2003 and 2013. Face-to-face visits with PCPs per quarter were identified through VHA administrative data. Comorbidity was measured using the Gagne index and patients with a weighted score of ≥ 2 were defined as high comorbidity. We applied interrupted time-series models to estimate marginal changes in PCP visits attributable to PCMH implementation. Differences in marginal changes were calculated across comorbidity groups (high vs. low). Analyses were stratified by age group to account for Medicare eligibility. KEY RESULTS: Among age 65+ patients, PCMH was associated with greater PCP visits starting four and ten quarters following implementation for high- and low-comorbidity patients, respectively. Changes were larger for high-comorbidity patients (eight to 11 greater visits per 1000 patients per quarter). Among patients age < 65, PCMH was associated with greater visits for high-comorbidity patients starting eight quarters following implementation, but fewer visits for low-comorbidity patients in all quarters. The difference in visit changes across groups ranged from 18 to 67 visits per 1000 patients per quarter. CONCLUSIONS: Increases in PCP visits attributable to PCMH were greater among patients with higher comorbidity. Health systems implementing PCMH should account for population-level comorbidity burden when planning for PCMH-related changes in PCP utilization.

Disparities in the diagnosis and pharmacologic treatment of high serum cholesterol by race and ethnicity: data from the Third National Health and Nutrition Examination Survey.

BACKGROUND: Serum cholesterol is one of the most important modifiable risk factors for coronary artery disease. There are conflicting data on racial and ethnic variation in the treatment of high cholesterol. METHODS: We analyzed data from the Third National Health and Nutrition Examination Survey, a nationally representative cross-sectional survey conducted between 1988 and 1994. Participants included 7679 white, 4467 African American, and 4113 Mexican American adults older than 25 years who completed the household adult questionnaire. The adjusted odds of serum cholesterol screening and of taking a prescription medication to lower serum cholesterol among African Americans and Mexican Americans were compared with those of whites, controlling for differences in age, sex, income, educational level, insurance status, comorbid illness, and having a regular source of health care. RESULTS: African Americans and Mexican Americans were significantly less likely than whites to report ever having had their blood cholesterol checked (odds ratio, 0.7 for both; P<.001). Among individuals with high cholesterol who were told to take a medication, African Americans (P<.001) and Mexican Americans (P =.05) were less likely than whites to be taking a cholesterol-lowering agent (odds ratios, 0.3 and 0.5, respectively). Individuals who reported being told they had high cholesterol had significantly higher serum cholesterol measurements (from the laboratory examination) than those who reported being told their cholesterol was not high (234 vs 198 mg/dL [6.05 vs 5.12 mmol/L]; P<.001). CONCLUSIONS: African Americans and Mexican Americans were less likely to report serum cholesterol screening than whites. Even when identified as having high cholesterol that required medication, African Americans and Mexican Americans were less likely than whites to be taking cholesterol-lowering agents.