A Pragmatic Approach to Identifying and Profiling Primary Care Clinicians and Primary Care Practices in the USA.

BACKGROUND: There are no consistent data on US primary care clinicians and primary care practices owing to the lack of standard methods to identify them, hampering efforts in primary care improvement. METHODS: We develop a pragmatic framework that identifies primary care clinicians and practices in the context of the US healthcare system, and applied the framework to the IQVIA OneKey Healthcare Professional database to identify and profile primary care clinicians and practices in the USA. RESULTS: Our framework prescribes sequential steps to identify primary care clinicians by cross-examining clinician specialties and organizational affiliations, and then identify primary care practices based on organization types and presence of primary care clinicians. Applying this framework to the 2021 IQVIA data, we identified 365,751 physicians with a primary specialty in primary care, and after excluding those who further specialized (24%), served as hospitalists (5%), or worked in non-primary care settings (41%), we determined that 179,369 (49%) of them were actually practicing primary care. We identified 287,506 nurse practitioners and 134,083 physician assistants and determined that 88,574 (31%) and 29,781 (22%), respectively, were delivering primary care. We identified 94,489 primary care practices, and found that 45% of them were with one primary care physician, 15% had two physicians, 12% employed nurse practitioners or physician assistants only, and 19% employed both primary care physicians and specialists. CONCLUSIONS: Our approach offers a pragmatic and consistent alternative to the diverse methods currently used to identify and profile primary care workforce and organizations in the USA.

Low-Intensity Intervention Supports Diabetes Registry Implementation: A Cluster-Randomized Trial in the Ambulatory Care Outcomes Research Network (ACORN).

BACKGROUND: Previous research demonstrated that registries are effective for improving clinical guideline adherence for the care of patients with type 2 diabetes. However, registry implementation has typically relied on intensive support (such as practice facilitators) for practice change and care improvement. OBJECTIVE: To determine whether a remotely delivered, low-intensity organizational change intervention supports implementation and use of diabetes registries in primary care. DESIGN: Cluster-randomized controlled effectiveness trial of providing limited external support leveraging internal practice resources and problem-solving capacities for driving diabetes registry implementation in 32 practices in Virginia. INTERVENTION: All practices identified local implementation champions who participated in an in-person education session on the value and use of diabetes registries, while intervention practices were also paired with peer mentors and had access to a physician informaticist, who worked remotely to assist practices with implementation. MAIN MEASURES: Practice champions reported progress on registry implementation milestone achievement, and reported practice-level organizational capacity by using a modified version of the Assessment of Chronic Illness Care (ACIC). KEY RESULTS: Intervention practices were significantly more likely to have implemented a registry (44% vs 6%, P = .04) and to have achieved more implementation milestones (5.5 vs 2.6, P < .0001) than control practices. Baseline ACIC scores indicated room for organizational improvement with regard to chronic illness care (overall median, 6.4; range, 3.8 to 10.8) and clinical information systems use (median, 6.0; range, 0 to 11) with no significant differences between intervention and control practices. CONCLUSIONS: Remotely provided guidance paired with limited in-person assistance can support rapid implementation of diabetes registries in typical primary care practices.

Using the Consolidated Framework for Implementation Research (CFIR) to produce actionable findings: a rapid-cycle evaluation approach to improving implementation.

BACKGROUND: Much research does not address the practical needs of stakeholders responsible for introducing health care delivery interventions into organizations working to achieve better outcomes. In this article, we present an approach to using the Consolidated Framework for Implementation Research (CFIR) to guide systematic research that supports rapid-cycle evaluation of the implementation of health care delivery interventions and produces actionable evaluation findings intended to improve implementation in a timely manner. METHODS: To present our approach, we describe a formative cross-case qualitative investigation of 21 primary care practices participating in the Comprehensive Primary Care (CPC) initiative, a multi-payer supported primary care practice transformation intervention led by the Centers for Medicare and Medicaid Services. Qualitative data include observational field notes and semi-structured interviews with primary care practice leadership, clinicians, and administrative and medical support staff. We use intervention-specific codes, and CFIR constructs to reduce and organize the data to support cross-case analysis of patterns of barriers and facilitators relating to different CPC components. RESULTS: Using the CFIR to guide data collection, coding, analysis, and reporting of findings supported a systematic, comprehensive, and timely understanding of barriers and facilitators to practice transformation. Our approach to using the CFIR produced actionable findings for improving implementation effectiveness during this initiative and for identifying improvements to implementation strategies for future practice transformation efforts. CONCLUSIONS: The CFIR is a useful tool for guiding rapid-cycle evaluation of the implementation of practice transformation initiatives. Using the approach described here, we systematically identified where adjustments and refinements to the intervention could be made in the second year of the 4-year intervention. We think the approach we describe has broad application and encourage others to use the CFIR, along with intervention-specific codes, to guide the efficient and rigorous analysis of rich qualitative data. TRIAL REGISTRATION: NCT02318108.

Early Experiences Engaging Patients Through Patient and Family Advisory Councils.

Primary care practices are increasingly asked to engage patients in improving care delivery. We report early experiences with Patient and Family Advisory Councils (PFACs) from interviews of patients and practice staff in the Comprehensive Primary Care initiative, and identify ways to improve PFACs. Patients and practice staff report PFACs help practices elicit patient feedback and, in response, improve care delivery. Nonetheless, there are areas for refinement, including recruiting more diverse patients, providing an orientation to members, overcoming reticence of some patients to raise issues, and increasing transparency by sharing progress with PFAC members and patients in the practice more generally.

Supporting Practices to Adopt Registry-Based Care (SPARC): protocol for a randomized controlled trial.

BACKGROUND: Diabetes is predicted to increase in incidence by 42% from 1995 to 2025. Although most adults with diabetes seek care from primary care practices, adherence to treatment guidelines in these settings is not optimal. Many practices lack the infrastructure to monitor patient adherence to recommended treatment and are slow to implement changes critical for effective management of patients with chronic conditions. Supporting Practices to Adopt Registry-Based Care (SPARC) will evaluate effectiveness and sustainability of a low-cost intervention designed to support work process change in primary care practices and enhance focus on population-based care through implementation of a diabetes registry. METHODS: SPARC is a two-armed randomized controlled trial (RCT) of 30 primary care practices in the Virginia Ambulatory Care Outcomes Research Network (ACORN). Participating practices (including control groups) will be introduced to population health concepts and tools for work process redesign and registry adoption at a meeting of practice-level implementation champions. Practices randomized to the intervention will be assigned study peer mentors, receive a list of specific milestones, and have access to a physician informaticist. Peer mentors are clinicians who successfully implemented registries in their practices and will help champions in the intervention practices throughout the implementation process. During the first year, peer mentors will contact intervention practices monthly and visit them quarterly. Control group practices will not receive support or guidance for registry implementation. We will use a mixed-methods explanatory sequential design to guide collection of medical record, participant observation, and semistructured interview data in control and intervention practices at baseline, 12 months, and 24 months. We will use grounded theory and a template-guided approach using the Consolidated Framework for Implementation Research to analyze qualitative data on contextual factors related to registry adoption. We will assess intervention effectiveness by comparing changes in patient-level hemoglobin A1c scores from baseline to year 1 between intervention and control practices. DISCUSSION: Findings will enhance our understanding of how to leverage existing practice resources to improve diabetes care in primary care practices by implementing and using a registry. SPARC has the potential to validate the effectiveness of low-cost implementation strategies that target practice change in primary care. TRIAL REGISTRATION: NCT02318108.

Revisit frequency and its association with quality of care among diabetic patients: Translating Research Into Action for Diabetes (TRIAD).

OBJECTIVE: To describe patient and provider characteristics associated with outpatient revisit frequency and to examine the associations between the revisit frequency and the processes and intermediate outcomes of diabetes care. RESEARCH DESIGN AND METHODS: We analyzed data from Translating Research Into Action for Diabetes (TRIAD), a prospective, multicenter, observational study of diabetes care in managed care. RESULTS: Our analysis included 6040 eligible adult participants with type 2 diabetes (42.6% ≥65 years of age, 54.1% female) whose primary care providers were the main provider of the participants' diabetes care. The median (interquartile range) revisit frequency was 4.0 (3.7, 6.0) visits per year. Being female, having lower education, lower income, more complex diabetes treatment, cardiovascular disease, higher Charlson comorbidity index, and impaired mobility were associated with higher revisit frequency. The proportion of participants who had annual assessments of HbA1c and LDL-cholesterol, foot examinations, advised or documented aspirin use, and influenza immunizations were higher for those with higher revisit frequency. The proportion of participants who met HbA1c (<9.5%) and LDL-cholesterol (<130 mg/dL) treatment goals were higher for those with a higher revisit frequency. The predicted probabilities of achieving more aggressive goals, HbA1c <8.5%, LDL-cholesterol <100mg/dL, and blood pressure <130/85 or even <140/90 mmHg were not associated with higher revisit frequency. CONCLUSIONS: Revisit frequency was highly variable and was associated with both sociodemographic characteristics and disease severity. A higher revisit frequency was associated with better processes of diabetes care, but the association with intermediate outcomes was less clear.

Electronic health record functionality needed to better support primary care.

Electronic health records (EHRs) must support primary care clinicians and patients, yet many clinicians remain dissatisfied with their system. This article presents a consensus statement about gaps in current EHR functionality and needed enhancements to support primary care. The Institute of Medicine primary care attributes were used to define needs and meaningful use (MU) objectives to define EHR functionality. Current objectives remain focused on disease rather than the whole person, ignoring factors such as personal risks, behaviors, family structure, and occupational and environmental influences. Primary care needs EHRs to move beyond documentation to interpreting and tracking information over time, as well as patient-partnering activities, support for team-based care, population-management tools that deliver care, and reduced documentation burden. While stage 3 MU's focus on outcomes is laudable, enhanced functionality is still needed, including EHR modifications, expanded use of patient portals, seamless integration with external applications, and advancement of national infrastructure and policies.

A typology of electronic health record workarounds in small-to-medium size primary care practices.

OBJECTIVE: Electronic health record (EHR) use in ambulatory care can improve safety and quality; however, problems with design, implementation, and poor interface with other systems lead users to develop 'workarounds', or behaviors users adopt to overcome perceived limitations in a technical system. We documented workarounds used in independent, community-based primary care practices, and developed a typology of their key features. MATERIALS AND METHODS: Comparative case study of EHR use in seven independent primary care practices. Field researchers spent approximately 1 month in each practice to observe EHR use, conduct patient pathways, and interview clinicians and staff. RESULTS: We observed workarounds addressing a wide range of EHR-related problems, including: user interface issues (eg, insufficient data fields, limited templates), barriers to electronic health information exchange with external organizations, and struggles incorporating new technologies into existing office space. We analyzed the observed workarounds inductively to develop a typology that cuts across specific clinical or administrative processes to highlight the following key formal features of workarounds in general: temporary/routinized, which captures whether the workaround is taken for granted as part of daily workflow or is understood as a short-term solution; avoidable/unavoidable, referring to the extent to which the workaround is within the practice's power to eliminate; and deliberately chosen/unplanned, which differentiates strategically chosen adaptations from less thoughtful workarounds. CONCLUSIONS: This workaround typology provides a framework for EHR users to identify and address workarounds in their own practices, and for researchers to examine the effect of different types of EHR workarounds on patient safety, care quality, and efficiency.

Medical costs associated with type 2 diabetes complications and comorbidities.

OBJECTIVES: To estimate the direct medical costs associated with type 2 diabetes, its complications, and its comorbidities among U.S. managed care patients. STUDY DESIGN: Data were from patient surveys, chart reviews, and health insurance claims for 7109 people with type 2 diabetes from 8 health plans participating in the Translating Research Into Action for Diabetes (TRIAD) study between 1999 and 2002. METHODS: A generalized linear regression model was developed to estimate the association of patients' demographic characteristics, tobacco use status, treatments, related complications, and comorbidities with medical costs. RESULTS: The mean annualized direct medical cost was $2465 for a white man with type 2 diabetes who had been diagnosed fewer than 15 years earlier, was treated with oral medication or diet alone, and had no complications or comorbidities. We found annualized medical costs to be 10% to 50% higher for women and for patients whose diabetes had been diagnosed 15 or more years earlier, who used tobacco, who were being treated with insulin, or who had several other complications. Coronary heart disease, congestive heart failure, hemiplegia, and amputation were each associated with 70% to 150% higher costs. Costs were approximately 300% higher for end-stage renal disease treated with dialysis and approximately 500% higher for end-stage renal disease with kidney transplantation. CONCLUSIONS: Most medical costs incurred by patients with type 2 diabetes are related to complications and comorbidities. Our cost estimates can help when determining the most cost-effective interventions to prevent complications and comorbidities.

Electronic health record impact on work burden in small, unaffiliated, community-based primary care practices.

BACKGROUND: The use of electronic health records (EHR) is widely recommended as a means to improve the quality, safety and efficiency of US healthcare. Relatively little is known, however, about how implementation and use of this technology affects the work of clinicians and support staff who provide primary health care in small, independent practices. OBJECTIVE: To study the impact of EHR use on clinician and staff work burden in small, community-based primary care practices. DESIGN: We conducted in-depth field research in seven community-based primary care practices. A team of field researchers spent 9-14 days over a 4-8 week period observing work in each practice, following patients through the practices, conducting interviews with key informants, and collecting documents and photographs. Field research data were coded and analyzed by a multidisciplinary research team, using a grounded theory approach. PARTICIPANTS: All practice members and selected patients in seven community-based primary care practices in the Northeastern US. KEY RESULTS: The impact of EHR use on work burden differed for clinicians compared to support staff. EHR use reduced both clerical and clinical staff work burden by improving how they check in and room patients, how they chart their work, and how they communicate with both patients and providers. In contrast, EHR use reduced some clinician work (i.e., prescribing, some lab-related tasks, and communication within the office), while increasing other work (i.e., charting, chronic disease and preventive care tasks, and some lab-related tasks). Thoughtful implementation and strategic workflow redesign can mitigate the disproportionate EHR-related work burden for clinicians, as well as facilitate population-based care. CONCLUSIONS: The complex needs of the primary care clinician should be understood and considered as the next iteration of EHR systems are developed and implemented.

Using multifactorial experiments for comparative effectiveness research in physician practices with electronic health record.

Two key challenges related to conducting comparative effectiveness research are the lack of available data and the lack of rigorous techniques for efficiently and quickly testing the effectiveness of the many possible ways of implementing components of care. The confluence of two things offers the promise of overcoming these challenges: (1) the increased adoption of electronic health records (EHRs), which can provide easier access to clinical information, and (2) burgeoning appreciation for an under-used but powerful statistical research and evaluation method for multifactor interventions known as multifactor experimental design. The use of multifactorial experiments paired with EHR data has great potential to help providers conduct rapid-cycle comparative effectiveness research and examine alternative ways of implementing care. Its power is its ability to enable scientifically rigorous testing of many facets of care provision simultaneously in real-world settings where change is ongoing. In this paper, we identify the opportunities for using efficient multifactorial designs and EHR data to evaluate quality-improvement efforts in physician practices. We illustrate the power of multifactorial designs through several examples relevant to physician practices with EHRs, such as evaluating clinical decision support features and studying components of a patient-centered medical home.

Evaluation of risk equations for prediction of short-term coronary heart disease events in patients with long-standing type 2 diabetes: the Translating Research into Action for Diabetes (TRIAD) study.

BACKGROUND: To evaluate the U.K. Prospective Diabetes Study (UKPDS) and Framingham risk equations for predicting short-term risk of coronary heart disease (CHD) events among adults with long-standing type 2 diabetes, including those with and without preexisting CHD. METHODS: Prospective cohort of U.S. managed care enrollees aged ≥ 18 years and mean diabetes duration of more than 10 years, participating in the Translating Research into Action for Diabetes (TRIAD) study, was followed for the first occurrence of CHD events from 2000 to 2003. The UKPDS and Framingham risk equations were evaluated for discriminating power and calibration. RESULTS: A total of 8303 TRIAD participants, were identified to evaluate the UKPDS (n = 5914, 120 events), Framingham-initial (n = 5914, 218 events) and Framingham-secondary (n = 2389, 374 events) risk equations, according to their prior CHD history. All of these equations exhibited low discriminating power with Harrell's c-index <0.65. All except the Framingham-initial equation for women and the Framingham-secondary equation for men had low levels of calibration. After adjsusting for the average values of predictors and event rates in the TRIAD population, the calibration of these equations greatly improved. CONCLUSIONS: The UKPDS and Framingham risk equations may be inappropriate for predicting the short-term risk of CHD events in patients with long-standing type 2 diabetes, partly due to changes in medications used by patients with diabetes and other improvements in clinical care since the Frmaingham and UKPDS studies were conducted. Refinement of these equations to reflect contemporary CHD profiles, diagnostics and therapies are needed to provide reliable risk estimates to inform effective treatment.

Typical electronic health record use in primary care practices and the quality of diabetes care.

PURPOSE: Recent efforts to encourage meaningful use of electronic health records (EHRs) assume that widespread adoption will improve the quality of ambulatory care, especially for complex clinical conditions such as diabetes. Cross-sectional studies of typical uses of commercially available ambulatory EHRs provide conflicting evidence for an association between EHR use and improved care, and effects of longer-term EHR use in community-based primary care settings on the quality of care are not well understood. METHODS: We analyzed data from 16 EHR-using and 26 non-EHR-using practices in 2 northeastern states participating in a group-randomized quality improvement trial. Measures of care were assessed for 798 patients with diabetes. We used hierarchical linear models to examine the relationship between EHR use and adherence to evidence-based diabetes care guidelines, and hierarchical logistic models to compare rates of improvement over 3 years. RESULTS: EHR use was not associated with better adherence to care guidelines or a more rapid improvement in adherence. In fact, patients in practices that did not use an EHR were more likely than those in practices that used an EHR to meet all of 3 intermediate outcomes targets for hemoglobin A(1c), low-density lipoprotein cholesterol, and blood pressure at the 2-year follow-up (odds ratio = 1.67; 95% CI, 1.12-2.51). Although the quality of care improved across all practices, rates of improvement did not differ between the 2 groups. CONCLUSIONS: Consistent use of an EHR over 3 years does not ensure successful use for improving the quality of diabetes care. Ongoing efforts to encourage adoption and meaningful use of EHRs in primary care should focus on ensuring that use succeeds in improving care. These efforts will need to include provision of assistance to longer-term EHR users.

Predictors of mortality over 8 years in type 2 diabetic patients: Translating Research Into Action for Diabetes (TRIAD).

OBJECTIVE: To examine demographic, socioeconomic, and biological risk factors for all-cause, cardiovascular, and noncardiovascular mortality in patients with type 2 diabetes over 8 years and to construct mortality prediction equations. RESEARCH DESIGN AND METHODS: Beginning in 2000, survey and medical record information was obtained from 8,334 participants in Translating Research Into Action for Diabetes (TRIAD), a multicenter prospective observational study of diabetes care in managed care. The National Death Index was searched annually to obtain data on deaths over an 8-year follow-up period (2000-2007). Predictors examined included age, sex, race, education, income, smoking, age at diagnosis of diabetes, duration and treatment of diabetes, BMI, complications, comorbidities, and medication use. RESULTS: There were 1,616 (19%) deaths over the 8-year period. In the most parsimonious equation, the predictors of all-cause mortality included older age, male sex, white race, lower income, smoking, insulin treatment, nephropathy, history of dyslipidemia, higher LDL cholesterol, angina/myocardial infarction/other coronary disease/coronary angioplasty/bypass, congestive heart failure, aspirin, ß-blocker, and diuretic use, and higher Charlson Index. CONCLUSIONS: Risk of death can be predicted in people with type 2 diabetes using simple demographic, socioeconomic, and biological risk factors with fair reliability. Such prediction equations are essential for computer simulation models of diabetes progression and may, with further validation, be useful for patient management.

Getting under the skin of clinical inertia in insulin initiation: the Translating Research Into Action for Diabetes (TRIAD) Insulin Starts Project.

PURPOSE: The purpose of this cross-sectional study is to explore primary care providers' (PCPs) perceptions about barriers to initiating insulin among patients. Studies suggest that many patients with poorly controlled type 2 diabetes do not receive insulin initiation by PCPs. METHODS: As part of the Translating Research Into Action for Diabetes study, the authors conducted structured interviews in health systems in Indiana, New Jersey, and California, asking PCPs about the importance of insulin initiation and factors affecting this decision. The authors calculated proportions choosing each multiple-choice response option and listed the most frequently offered open-ended response categories. RESULTS: Among 83 PCPs, 45% were women; 60% were white; and they averaged 13.4 years in practice. Four-fifths of PCPs endorsed guideline-concordant glycemic targets, but 54% individualized targets based on patient age, life expectancy, medical comorbidities, self-management capacity, and willingness. Most (64%) reported that many patients were resistant to new oral or insulin therapies due to fears about the therapy and what it meant about their disease progression. Two-thirds (64%) cited patient resistance as a barrier to insulin initiation, and 43% cited problems with patient self-management, including cognitive or mental health issues, dexterity, or ability to adhere. Eighty percent felt that patient nonadherence would dissuade them from initiating insulin at least some of the time. CONCLUSIONS: PCPs perceived that patient resistance and poor self- management skills were significant barriers to initiating insulin. Future studies should investigate whether systems-level interventions to improve patient-provider communication about insulin and enhance providers' perceptions of patient self-management capacity can increase guideline-concordant, patient-centered insulin initiation.

Early adopters of electronic prescribing struggle to make meaningful use of formulary checks and medication history documentation.

INTRODUCTION: Use of electronic prescribing (e-prescribing) can improve safety and reduce costs of care by alerting prescribers to drug-drug interactions, patient nonadherence to therapies, and insurance coverage information. Deriving these benefits will require clinical decision support based on presentation of accurate and complete formulary and benefit (F&B) and medication history (RxH) data to prescribers, but relatively little is known about how this information is used in primary care. METHODS: This is a multimethod comparative case study of 8 practices, which were selected to ensure practice size and physician specialty variation, implementing a stand-alone e-prescribing program. Field researchers observed prescription workflow and interviewed physicians and office staff. RESULTS: Before implementation, few prescribers reported using F&B references when making medication choices; all used paper-based methods for tracking medication history. After implementation, some prescribers reported using F&B data to inform medication choices but missing information reduced confidence in these resources. Low confidence in RxH data led to paper-based workarounds. CONCLUSIONS: Challenges experienced with formulary checks and RxH documentation led to prescriber distrust and unwillingness to rely on e-prescribing-based information. Greater data accuracy and completeness must be assured if e-prescribing is to meet meaningful use objectives to improve the efficiency and safety of prescribing in primary care settings.

EHR implementation without meaningful use can lead to worse outcomes.

Defying expectations, typical electronic health record (EHR) use in practices belonging to a primary care network has been associated with poorer diabetes care quality and outcomes. Current expansion of primary care EHR implementation must focus on use that improves care.

Meaningful use of electronic prescribing in 5 exemplar primary care practices.

PURPOSE: Successful use of electronic prescribing (e-prescribing) is a key requirement for demonstrating meaningful use of electronic health records to qualify for federal incentives. Currently, many physicians who implement e-prescribing fail to make substantial use of these systems, and little is known about factors contributing to successful e-prescribing use. The objective of this study was to identify successful implementation and use techniques. METHODS: We conducted a multimethod qualitative case study of 5 ambulatory primary care practices identified as exemplars of effective e-prescribing. The practices were identified by a group of e-prescribing experts. Field researchers conducted in-depth interviews and observed prescription-related workflow in these practices. RESULTS: In these exemplar practices, successful use of e-prescribing required practice transformation. Practice members reported extensive efforts to redesign work processes to take advantage of e-prescribing capabilities and to create specific e-prescribing protocols to distribute prescription-related work among practice team members. These practices had substantial resources to support e-prescribing use, including local physician champions, ongoing training for practice members, and continuous on-site technical support. Practices faced considerable challenges during use of e-prescribing, however, deriving from problems coordinating new work processes with pharmacies and ineffective health information exchange that required workarounds to ensure the completeness of patient medical records. CONCLUSIONS: More widespread implementation and effective use of e-prescribing in ambulatory care settings will require practice transformation efforts that focus on work process redesign while being attentive to effects on patient and pharmacy involvement in prescribing. Improved health information exchange is required to fully realize expected quality, safety, and efficiency gains of e-prescribing.