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BACKGROUND: Using a health systems approach to investigate low-value care (LVC) may provide insights into structural drivers of this pervasive problem. OBJECTIVE: To evaluate the influence of service area practice patterns on low-value mammography and prostate-specific antigen (PSA) testing. DESIGN: Retrospective study analyzing LVC rates between 2008 and 2018, leveraging physician relocation in 3-year intervals of matched physician and patient groups. SETTING: U.S. Medicare claims data. PARTICIPANTS: 8254 physicians and 56 467 patients aged 75 years or older. MEASUREMENTS: LVC rates for physicians staying in their original service area and those relocating to new areas. RESULTS: Physicians relocating from higher-LVC areas to low-LVC areas were more likely to provide lower rates of LVC. For mammography, physicians staying in high-LVC areas (LVC rate, 10.1% [95% CI, 8.8% to 12.2%]) or medium-LVC areas (LVC rate, 10.3% [CI, 9.0% to 12.4%]) provided LVC at a higher rate than physicians relocating from those areas to low-LVC areas (LVC rates, 6.0% [CI, 4.4% to 7.5%] [difference, -4.1 percentage points {CI, -6.7 to -2.3 percentage points}] and 5.9% [CI, 4.6% to 7.8%] [difference, -4.4 percentage points {CI, -6.7 to -2.4 percentage points}], respectively). For PSA testing, physicians staying in high- or moderate-LVC service areas provided LVC at a rate of 17.5% (CI, 14.9% to 20.7%) or 10.6% (CI, 9.6% to 13.2%), respectively, compared with those relocating from those areas to low-LVC areas (LVC rates, 9.9% [CI, 7.5% to 13.2%] [difference, -7.6 percentage points {CI, -10.9 to -3.8 percentage points}] and 6.2% [CI, 3.5% to 9.8%] [difference, -4.4 percentage points {CI, -7.6 to -2.2 percentage points}], respectively). Physicians relocating from lower- to higher-LVC service areas were not more likely to provide LVC at a higher rate. LIMITATION: Use of retrospective observational data, possible unmeasured confounding, and potential for relocating physicians to practice differently from those who stay. CONCLUSION: Physicians relocating to service areas with lower rates of LVC provided less LVC than physicians who stayed in areas with higher rates of LVC. Systemic structures may contribute to LVC. Understanding which factors are contributing may present opportunities for policy and interventions to broadly improve care. PRIMARY FUNDING SOURCE: National Cancer Institute of the National Institutes of Health.
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Neoplasias da Mama , Detecção Precoce de Câncer , Mamografia , Medicare , Padrões de Prática Médica , Antígeno Prostático Específico , Neoplasias da Próstata , Humanos , Masculino , Estudos Retrospectivos , Feminino , Idoso , Estados Unidos , Antígeno Prostático Específico/sangue , Mamografia/estatística & dados numéricos , Detecção Precoce de Câncer/estatística & dados numéricos , Neoplasias da Mama/diagnóstico , Neoplasias da Próstata/diagnóstico , Padrões de Prática Médica/estatística & dados numéricos , Médicos de Atenção Primária/estatística & dados numéricos , Idoso de 80 Anos ou maisRESUMO
BACKGROUND: While evidence supports interprofessional primary care models that include pharmacists, the extent to which pharmacists are working in primary care and the factors associated with colocation is unknown. OBJECTIVES: This study aimed to analyze the physical colocation of pharmacists with primary care providers (PCPs) and examine predictors associated with colocation. RESEARCH DESIGN: This is a retrospective cross-sectional study of pharmacists and PCPs with individual National Provider Identifiers in the National Plan and Provider Enumeration System's database. Pharmacist and PCP practice addresses of the health care professionals were geocoded, and distances less than 0.1 miles were considered physically colocated. SUBJECTS: In all, 502,373 physicians and 221,534 pharmacists were included. RESULTS: When excluding hospital-based pharmacists, 1 in 10 (11%) pharmacists were colocated with a PCP. Pharmacists in urban settings were more likely to be colocated than those in rural areas (OR=1.32, CI: 1.26-1.38). Counties with the highest proportion of licensed pharmacists per 100,000 people in the county had higher colocation (OR=1.38, CI: 1.32-1.45). Colocation was significantly higher in states with an expanded scope of practice (OR 1.37, CI: 1.32-1.42) and those that have expanded Medicaid (OR 1.07, CI: 1.03-1.11). Colocated pharmacists more commonly worked in larger physician practices. CONCLUSION: Although including pharmacists on primary care teams improves clinical outcomes, reduces health care costs, and enhances patient and provider experience, colocation appears to be unevenly dispersed across the United States, with lower rates in rural areas. As the integration of pharmacists in primary care continues to expand, knowing the prevalence and facilitators of growth will be helpful to policymakers, researchers, and clinical administrators.
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Farmacêuticos , Médicos de Atenção Primária , Humanos , Estados Unidos , Estudos Transversais , Estudos Retrospectivos , Atenção Primária à SaúdeRESUMO
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.
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Médicos de Atenção Primária , Atenção Primária à Saúde , Humanos , Atenção Primária à Saúde/organização & administração , Estados Unidos , Bases de Dados FactuaisRESUMO
BACKGROUND: Burnout among providers negatively impacts patient care experiences and safety. Providers at Federally Qualified Health Centers (FQHC) are at high risk for burnout due to high patient volumes; inadequate staffing; and balancing the demands of patients, families, and team members. OBJECTIVE: Examine associations of provider burnout with their perspectives on quality improvement (QI), patient experience measurement, clinic culture, and job satisfaction. DESIGN: We conducted a cross-sectional provider survey about their perspectives including the single-item burnout measure. We fit separate regression models, controlling for provider type, gender, being multilingual, and fixed effects for clinic predicting outcome measures from burnout. PARTICIPANTS: Seventy-four providers from 44 clinics in large, urban FQHC (52% response rate; n = 174). MAIN MEASURES: Survey included a single-item, self-defined burnout measure adapted from the Physician Worklife Survey, and measures from the RAND AMA Study survey, Heath Tracking Physician survey, TransforMed Clinician and Staff Questionnaire, Physician Worklife Survey, Minimizing Errors Maximizing Outcomes survey, and surveys by Friedberg et al. 31 and Walling et al. 32 RESULTS: Thirty percent of providers reported burnout. Providers in clinics with more facilitative leadership reported not being burned out (compared to those reporting burnout; p-values < 0.05). More pressures related to patient care and lower job satisfaction were associated with burnout (p-values < 0.05). CONCLUSIONS: Creating provider-team relationships and environments where providers have the time and space necessary to discuss changes to improve care, ideas are shared, leadership supports QI, and QI is monitored and discussed were related to not being burned out. Reducing time pressures and improving support needed for providers to address the high-need levels of FQHC patients can also decrease burnout. Such leadership and support to improving care may be a separate protective factor against burnout. Research is needed to further examine which aspects of leadership drive down burnout and increase provider involvement in change efforts and improving care.
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Esgotamento Profissional , Satisfação no Emprego , Satisfação do Paciente , Melhoria de Qualidade , Humanos , Esgotamento Profissional/psicologia , Esgotamento Profissional/epidemiologia , Masculino , Feminino , Estudos Transversais , Atenção Primária à Saúde/normas , Adulto , Pessoa de Meia-Idade , Cultura Organizacional , Inquéritos e Questionários , Médicos de Atenção Primária/psicologia , Médicos de Atenção Primária/normasRESUMO
BACKGROUND: There is growing, widespread recognition that expectations of US primary care vastly exceed the time and resources allocated to it. Little research has directly examined how time scarcity contributes to harm or patient safety incidents not readily capturable by population-based quality metrics. OBJECTIVE: To examine near-miss events identified by primary care physicians in which taking additional time improved patient care or prevented harm. DESIGN: Qualitative study based on semi-structured interviews. PARTICIPANTS: Twenty-five primary care physicians practicing in the USA. APPROACH: Participants completed a survey that included demographic questions, the Ballard Organizational Temporality Scale and the Mini-Z scale, followed by a one hour qualitative interview over video-conference (Zoom). Iterative thematic qualitative data analysis was conducted. KEY RESULTS: Primary care physicians identified several types of near-miss events in which taking extra time during visits changed their clinical management. These were evident in five types of patient care episodes: high-risk social situations, high-risk medication regimens requiring patient education, high acuity conditions requiring immediate workup or treatment, interactions of physical and mental health, and investigating more subtle clinical suspicions. These near-miss events highlight the ways in which unreasonably large patient panels and packed schedules impede adequate responses to patient care episodes that are time sensitive and intensive or require flexibility. CONCLUSIONS: Primary care physicians identify and address patient safety issues and high-risk situations by spending more time than allotted for a given patient encounter. Current quality metrics do not account for this critical aspect of primary care work. Current healthcare policy and organization create time scarcity. Interventions to address time scarcity and to measure its prevalence and implications for care quality and safety are urgently needed.
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Segurança do Paciente , Atenção Primária à Saúde , Humanos , Segurança do Paciente/normas , Atenção Primária à Saúde/normas , Feminino , Masculino , Pessoa de Meia-Idade , Adulto , Médicos de Atenção Primária , Qualidade da Assistência à Saúde/normas , Pesquisa Qualitativa , Fatores de TempoRESUMO
BACKGROUND: The efficiencies of plasma Alzheimer's disease (AD) biomarkers could facilitate early AD diagnosis. Unfortunately, limited knowledge exists about whether and how they would be used by clinicians. OBJECTIVE: To identify and compare determinants of plasma AD biomarker use reported by primary care providers and dementia specialists. DESIGN: Semi-structured interviews with clinicians organized using Rogers' Diffusion of Innovations theory and analyzed using an iterative coding approach. PARTICIPANTS: The subjects were internal and family medicine, neurology, and geriatrics providers with varying degrees of expertise in dementia diagnosis and care. MAIN MEASURES: Factors influencing a clinician's decision to use or not use plasma AD biomarkers in clinical practice. KEY RESULTS: We interviewed 30 clinicians (16 family or internal medicine providers, 8 geriatricians, and 6 neurologists). Fifteen were dementia specialists. Hesitance to use plasma AD biomarkers was due to perceived lack of effective treatments for AD, limited access to supports, and stigma. Plasma AD biomarkers would be more readily adopted by clinicians with dementia expertise. CONCLUSIONS: Several factors will influence clinical use of plasma AD biomarkers. Some of them may inform the design of interventions to promote the effective and appropriate clinical translation of these tests.
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Doença de Alzheimer , Biomarcadores , Atenção Primária à Saúde , Humanos , Doença de Alzheimer/sangue , Doença de Alzheimer/diagnóstico , Biomarcadores/sangue , Feminino , Masculino , Demência/diagnóstico , Demência/sangue , Médicos de Atenção PrimáriaRESUMO
BACKGROUND: In Spain, the risk of imported malaria has increased in recent years due to the rise in international travel and migration. Little is known about the knowledge, information sources, clinical practice, and specific needs of primary care physicians (PCPs) concerning malaria despite the pivotal role played by these professionals in managing the health of tourists. The objective of this study was to assess the knowledge, attitudes, and practices of PCPs in Spain regarding malaria. METHODS: This research analyses data from (1) a cross-sectional nationwide survey assessing the knowledge and attitudes of PCPs regarding malaria, and (2) a retrospective review of 373 malaria cases appearing in primary care medical records (PCMRs) in the Madrid area over the past 15 years to determine how cases were documented, managed, or characterized in the primary care setting. RESULTS: The survey findings reveal a modest level of self-perceived familiarity with malaria (221/360, 57.6%), even though 32.8% of the practitioners reported having delivered care for confirmed or suspected cases of the disease, these practitioners had greater knowledge of malaria (80.4%) compared to physicians who reported not having delivered care for malaria (19.6%, p < 0.001). Ten percent of the survey participants did not know the name of the mosquito that transmits malaria, and only 40.7% would promptly request malaria testing for a traveller with symptoms after a trip to an endemic area. Responses provided by younger PCPs varied to a greater extent than those of their more experienced colleagues regarding prevention practices and patient management. A review of PCMRs showed that only 65% of all patients were recorded as such. Among those registered, only 40.3% had a documented malaria episode, and of those, only 16.6% received proper follow-up. Only 23.7% of the patients with a PCMR had a record that specifically indicated travel to an endemic country or travel classified as visiting friends and relatives (VFR). CONCLUSIONS: The findings of this study underscore the critical role of PCPs in the field of travel medicine, particularly given the increase in imported malaria cases. These results highlight the need for targeted training in travel medicine and the need to ensure optimal patient education in care settings.
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Antimaláricos , Malária , Médicos de Atenção Primária , Humanos , Antimaláricos/uso terapêutico , Estudos Transversais , Malária/epidemiologia , Estudos Retrospectivos , Espanha/epidemiologia , ViagemRESUMO
BACKGROUND: We sought to examine the association between primary care physician (PCP) follow-up on readmission following gastrointestinal (GI) cancer surgery. METHODS: Patients who underwent surgery for GI cancer were identified using the Surveillance, Epidemiology and End Results (SEER) database. Multivariable regression was performed to examine the association between early PCP follow-up and hospital readmission. RESULTS: Among 60 957 patients who underwent GI cancer surgery, 19 661 (32.7%) visited a PCP within 30-days after discharge. Of note, patients who visited PCP were less likely to be readmitted within 90 days (PCP visit: 17.4% vs. no PCP visit: 28.2%; p < 0.001). Median postsurgical expenditures were lower among patients who visited a PCP (PCP visit: $4116 [IQR: $670-$13 860] vs. no PCP visit: $6700 [IQR: $870-$21 301]; p < 0.001). On multivariable analysis, PCP follow-up was associated with lower odds of 90-day readmission (OR: 0.52, 95% CI: 0.50-0.55) (both p < 0.001). Moreover, patients who followed up with a PCP had lower risk of death at 90-days (HR: 0.50, 95% CI: 0.40-0.51; p < 0.001). CONCLUSION: PCP follow-up was associated with a reduced risk of readmission and mortality following GI cancer surgery. Care coordination across in-hospital and community-based health platforms is critical to achieve optimal outcomes for patients.
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Neoplasias Gastrointestinais , Readmissão do Paciente , Médicos de Atenção Primária , Programa de SEER , Humanos , Readmissão do Paciente/estatística & dados numéricos , Readmissão do Paciente/economia , Masculino , Feminino , Neoplasias Gastrointestinais/cirurgia , Pessoa de Meia-Idade , Idoso , Seguimentos , Médicos de Atenção Primária/estatística & dados numéricos , Assistência ao Convalescente/estatística & dados numéricos , Assistência ao Convalescente/economia , Complicações Pós-Operatórias/epidemiologia , Procedimentos Cirúrgicos do Sistema DigestórioRESUMO
INTRODUCTION: Despite increasing prevalence of substance use disorders (SUD), few patients are diagnosed and treated in primary care settings. This study evaluated changes in knowledge, confidence, and intention to implement screening and brief intervention (SBI) and SUD treatment after clinicians participated in an asynchronous online education course. METHODS: A self-selected sample of primary care clinicians in Texas participated in online SBI and SUD education March 2021-July 2023. Baseline and post-training surveys evaluated changes in knowledge, confidence, and intent to implement SBI and SUD treatment. Changes were compared using paired t-tests. Multivariable linear regression examined factors potentially associated with confidence and intention to implement changes. Clinician feedback regarding the course was included. RESULTS: Of 613 respondents, 50.9% were practicing family medicine clinicians. Knowledge of adolescent screening tools increased from 21.9% to 75.7% (p < 0.001). Knowledge about the number of drinks that define excessive drinking among non-pregnant women increased from 24.5% at baseline to 64.9% (p < 0.001). Clinicians reported lowest confidence in providing opioid use disorder pharmacotherapy, which improved after program participation. Intent to implement SBI and medication for alcohol, nicotine and opioid use disorders increased (p < 0.001) after training. No factors were associated with change in confidence or intention to implement in multivariable models (p > 0.05). Satisfaction was high and nearly 60% reported intention to change their clinical practice because of the program. CONCLUSION: Knowledge, confidence, and intent to implement SBI and SUD treatment increased after completing the online course. Clinician satisfaction was high and demonstrated improved intention to implement SBI and SUD treatment.
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Atenção Primária à Saúde , Transtornos Relacionados ao Uso de Substâncias , Humanos , Texas , Transtornos Relacionados ao Uso de Substâncias/terapia , Feminino , Masculino , Inquéritos e Questionários , Adulto , Conhecimentos, Atitudes e Prática em Saúde , Pessoa de Meia-Idade , Educação a Distância/métodos , Programas de Rastreamento , Médicos de Atenção Primária/educação , IntençãoRESUMO
PURPOSE: The purpose of this study is to evaluate recent trends in primary care physician (PCP) electronic health record (EHR) workload. METHODS: This longitudinal study observed the EHR use of 141 academic PCPs over 4 years (May 2019 to March 2023). Ambulatory full-time equivalency (aFTE), visit volume, and panel size were evaluated. Electronic health record time and inbox message volume were measured per 8 hours of scheduled clinic appointments. RESULTS: From the pre-COVID-19 pandemic year (May 2019 to February 2020) to the most recent study year (April 2022 to March 2023), the average time PCPs spent in the EHR per 8 hours of scheduled clinic appointments increased (+28.4 minutes, 7.8%), as did time in orders (+23.1 minutes, 58.9%), inbox (+14.0 minutes, 24.4%), chart review (+7.2 minutes, 13.0%), notes (+2.9 minutes, 2.3%), outside scheduled hours on days with scheduled appointments (+6.4 minutes, 8.2%), and on unscheduled days (+13.6 minutes, 19.9%). Primary care physicians received more patient medical advice requests (+5.4 messages, 55.5%) and prescription messages (+2.3, 19.5%) per 8 hours of scheduled clinic appointments, but fewer patient calls (-2.8, -10.5%) and results messages (-0.3, -2.7%). While total time in the EHR continued to increase in the final study year (+7.7 minutes, 2.0%), inbox time decreased slightly from the year prior (-2.2 minutes, -3.0%). Primary care physicians' average aFTE decreased 5.2% from 0.66 to 0.63 over 4 years. CONCLUSIONS: Primary care physicians' time in the EHR continues to grow. While PCPs' inbox time may be stabilizing, it is still substantially higher than pre-pandemic levels. It is imperative health systems develop strategies to change the EHR workload trajectory to minimize PCPs' occupational stress and mitigate unnecessary reductions in effective physician workforce resulting from the increased EHR burden.
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Registros Eletrônicos de Saúde , Médicos de Atenção Primária , Humanos , Estudos Longitudinais , Pandemias , Carga de TrabalhoRESUMO
PURPOSE: We conducted a study to understand primary care physician (PCP) and urologist perspectives on determinants of active surveillance care delivery for men with low-risk prostate cancer. METHODS: We conducted in-depth, semistructured, virtual interviews with a purposive sample of 19 PCPs and 15 urologists between June 2020 and March 2021. We used the behavioral theory-informed Theoretical Domains Framework to understand barriers to and facilitators of active surveillance care delivery. Interviews were recorded, transcribed, and deductively coded into framework domains and constructs by 3 independent coders. Participant recruitment continued until data saturation by group. RESULTS: Our study included 19 PCPs (9 female; 4 in community practices, 15 in academic medical centers) and 15 urologists (3 female; 5 in private practice, 3 in academic medical centers). The most commonly reported Theoretical Domains Framework domains affecting active surveillance care were (1) knowledge and (2) environmental context and resources. Although urologists were knowledgeable about active surveillance, PCPs mentioned limitations in their understanding of active surveillance (eg, what follow-up entails). Both groups noted the importance of an informed patient, especially how a patient's understanding of active surveillance facilitates their receipt of recommended follow-up. Physicians viewed patient loss to follow-up as a barrier, but identified a favorable organizational culture/climate (eg, good communication between physicians) as a facilitator. CONCLUSIONS: With patients increasingly involving their PCPs in their cancer care, our study presents factors both PCPs and urologists perceive (or identify) as affecting optimal active surveillance care delivery. We provide insights that can help inform multilevel supportive interventions for patients, physicians, and organizations to ensure the success of active surveillance as a management strategy for low-risk prostate cancer.
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Médicos de Atenção Primária , Neoplasias da Próstata , Masculino , Humanos , Urologistas , Conduta Expectante , Neoplasias da Próstata/diagnóstico , Neoplasias da Próstata/terapia , Centros Médicos AcadêmicosRESUMO
This article studies the impact of primary care providers (PCPs) exit from the local health care system on patients' health care utilization. I compare patients with each other whose physicians have left the local health care system at different points in time due to retirement, relocation, or other reasons. Estimation results indicate that the imminent exit leads soon-leaving physicians to changing their treatment behavior, which has a significant impact on patients' health care spending. In addition, successors and new PCPs provide significantly more preventive services in the post-exit-period and refer patients more often to specialists for further examinations than the physicians who exit later. The increased inpatient expenditures in the post-exit period are caused by the new PCPs (through referrals). Self-initiated substitution behavior of patients (e.g., less PCP care, more specialist care) after the exit is observed but is low in magnitude. Although an overall increase in health service utilization is observed, mortality in the post-exit periods is significantly increased among affected patients. A possible explanation is the low frequency follow-up care of patients who were referred to hospitals by their former PCP in the notification-period.
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Médicos de Atenção Primária , Médicos , Humanos , Atenção à Saúde , Encaminhamento e Consulta , Aceitação pelo Paciente de Cuidados de Saúde , Atenção Primária à SaúdeRESUMO
BACKGROUND: Postnatal mental health problems (PMHPs) are prevalent and negatively affect mothers, children, and society. International and local guidelines recommend that Singapore primary care physicians (PCP) screen, assess, and manage mothers with PMHPs. However, little is known about their experiences and views. METHODS: We conducted semi-structured interviews with 14 PCPs in Singapore. Interview questions elicited perspectives on the identification and management of mothers with PMHPs. The interview guide was developed from a conceptual framework incorporating the knowledge-attitudes-practices, self-efficacy, and socio-ecological models. Interviews were audio-recorded and transcribed. Thematic analysis was used to identify emergent themes. RESULTS: Singapore PCPs viewed themselves as key providers of first-contact care to mothers with PMHPs. They believed mothers preferred them to alternative providers because of greater accessibility and trust. In detection, they were vigilant in identifying at-risk mothers and favoured clinical intuition over screening tools. PCPs were confident in diagnosing common PMHPs and believed that mothers not meeting diagnostic criteria must be readily recognized and supported. In managing PMHPs, PCPs expressed varying confidence in prescribing antidepressants, which were viewed as second-line to supportive counselling and psychoeducation. Impeding physician factors, constraining practice characteristics and health system limitations were barriers. Looking forward, PCPs aspired to leverage technology and multidisciplinary teams to provide comprehensive, team-based care for the mother-child dyad. CONCLUSION: Singapore PCPs are key in identifying and managing mothers with PMHPs. To fully harness their potential in providing comprehensive care, PCPs need greater multidisciplinary support and technological solutions that promote remote disclosure and enhanced preparation for their role.
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Médicos de Atenção Primária , Humanos , Médicos de Atenção Primária/psicologia , Saúde Mental , Atitude do Pessoal de Saúde , SingapuraRESUMO
BACKGROUND: Despite regular consultation between adolescents/young adults (AYA) and their physicians, they are not regularly screened for psychosocial risk behaviours. This study examines physicians' self-reported psychosocial risk behaviour screening in AYA. It aims to highlight which elements hinder or improve screening abilities. METHODOLOGY: The design was a cross-sectional quantitative survey. Data were obtained through a self-reported questionnaire sent out to primary care physicians (PCP) in Switzerland in 2018. The target population consisted of 1,824 PCP (29% response rate). Participants were asked whether they screened youths from 3 age groups [10-14 y/o, 15-20 y/o, and 21-25y/o] for the HEEADSSS items during child well visits and routine checkups. Barriers to screening included primary consultation motive prioritization, insufficient time, patient compliance, reimbursement, lack of skills related to adolescent health, lack of referral options. Data were analysed first through a bivariate analysis using Chi-square tests then through a multinomial logistic regression. RESULTS: The majority of physicians partook in preventive screening for 3-5 psychosocial risk elements. They reported the primary consultation motive as well as a lack of available time as having a high impact on their screening habits. Physician's experience and having discussed confidentiality were related to an increase in the number of topics addressed. Confidentiality remained a significant variable throughout all analyses. CONCLUSION: Barriers such as lack of consultation time and prioritization issues were found by physicians to be critical but did not hinder screening habits. The main element impacting screening habits was assuring confidentiality and the second is self-efficacy.
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Médicos de Atenção Primária , Médicos , Adolescente , Criança , Humanos , Estudos Transversais , Atenção Primária à Saúde , Assunção de Riscos , Inquéritos e Questionários , Adulto Jovem , AdultoRESUMO
INTRODUCTION: The clinical reasoning literature has increasingly considered context as an important influence on physicians' thinking. Physicians' relationships with patients, and their ongoing efforts to maintain these relationships, are important influences on how clinical reasoning is contextualised. The authors sought to understand how physicians' relationships with patients shaped their clinical reasoning. METHODS: Drawing from constructivist grounded theory, the authors conducted semi-structured interviews with primary care physicians. Participants were asked to reflect on recent challenging clinical experiences, and probing questions were used to explore how participants attended to or leveraged relationships in conjunction with their clinical reasoning. Using constant comparison, three investigators coded transcripts, organising the data into codes and conceptual categories. The research team drew from these codes and categories to develop theory about the phenomenon of interest. RESULTS: The authors interviewed 15 primary care physicians with a range of experience in practice and identified patient agency as a central influence on participants' clinical reasoning. Participants drew from and managed relationships with patients while attending to patients' agency in three ways. First, participants described how contextualised illness constructions enabled them to individualise their approaches to diagnosis and management. Second, participants managed tensions between enacting their typical approaches to clinical problems and adapting their approaches to foster ongoing relationships with patients. Finally, participants attended to relationships with patients' caregivers, seeing these individuals' contributions as important influences on how their clinical reasoning could be enacted within patients' unique social contexts. CONCLUSION: Clinical reasoning is influenced in important ways by physicians' efforts to both draw from, and maintain, their relationships with patients and patients' caregivers. Such efforts create tensions between their professional standards of care and their orientations toward patient-centredness. These influences of relationships on physicians' clinical reasoning have important implications for training and clinical practice.
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Raciocínio Clínico , Teoria Fundamentada , Relações Médico-Paciente , Humanos , Feminino , Masculino , Médicos de Atenção Primária/psicologia , Entrevistas como Assunto , Pesquisa Qualitativa , Adulto , Pessoa de Meia-Idade , Atitude do Pessoal de SaúdeRESUMO
STUDY OBJECTIVE: Falls are the leading cause of injuries in the US for older adults. Follow-up after an ED-related fall visit is essential to initiate preventive strategies in these patients who are at very high risk for recurrent falls. It is currently unclear how frequently follow-up occurs and whether preventive strategies are implemented. Our objective is to determine the rate of follow-up by older adults who sustain a fall related head injury resulting in an ED visit, the rate and type of risk assessment and adoption of preventive strategies. METHODS: This 1-year prospective observational study was conducted at two South Florida hospitals. All older ED patients with an acute head injury due to a fall were identified. Telephone surveys were conducted 14 days after ED presentation asking about PCP follow-up and adoption of fall prevention strategies. Clinical and demographic characteristics were compared between patients with and without follow up. RESULTS: Of 4951 patients with a head injury from a fall, 1527 met inclusion criteria. 905 reported follow-up with their PCP. Of these, 72% reported receiving a fall assessment and 56% adopted a fall prevention strategy. Participants with PCP follow-up were significantly more likely to have a history of cancer or hypertension. CONCLUSION: Only 60% of ED patients with fall-related head injury follow-up with their PCP. Further, 72% received a fall assessment and only 56% adopted a fall prevention strategy. These data indicate an urgent need to promote PCP fall assessment and adoption of prevention strategies in these patients.
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Traumatismos Craniocerebrais , Médicos de Atenção Primária , Idoso , Humanos , Traumatismos Craniocerebrais/epidemiologia , Serviço Hospitalar de Emergência , Seguimentos , Avaliação Geriátrica , Fatores de Risco , Estudos ProspectivosRESUMO
BACKGROUND: Benzodiazepines and other sedative hypnotic drugs (BSHs) are frequently prescribed for sleep problems, but cause substantial adverse effects, particularly in older adults. Improving knowledge on barriers, facilitators and needs of primary care providers (PCPs) to BSH deprescribing could help reduce BSH use and thus negative effects. METHODS: We conducted a mixed methods study (February-May 2023) including a survey, semi-structured interviews and focus groups with PCPs in Switzerland. We assessed barriers, facilitators and needs of PCPs to BSH deprescribing. Quantitative data were analyzed descriptively, qualitative data deductively and inductively using the Theoretical Domain Framework (TDF). Quantitative and qualitative data were integrated using meta-interferences. RESULTS: The survey was completed by 126 PCPs (53% female) and 16 PCPs participated to a focus group or individual interview. The main barriers to BSH deprescribing included patient and PCP lack of knowledge on BSH effects and side effects, lack of PCP education on treatment of sleep problems and BSH deprescribing, patient lack of motivation, PCP lack of time, limited access to cognitive behavioral therapy for insomnia and absence of public dialogue on BSHs. Facilitators included informing on side effects to motivate patients to discontinue BSHs and start of deprescribing during a hospitalization. Main PCP needs were practical recommendations for pharmacological and non-pharmacological treatment of sleep problems and deprescribing schemes. Patient brochures were wished by 69% of PCPs. PCPs suggested the brochures to contain explanations about risks and benefits of BSHs, sleep hygiene and sleep physiology, alternative treatments, discontinuation process and tapering schemes. CONCLUSION: The barriers and facilitators as well as PCP needs and opinions on patient material we identified can be used to develop PCP training and material on BSH deprescribing, which could help reduce the inappropriate use of BSHs for sleep problems.
Assuntos
Benzodiazepinas , Desprescrições , Hipnóticos e Sedativos , Humanos , Feminino , Masculino , Hipnóticos e Sedativos/uso terapêutico , Idoso , Benzodiazepinas/uso terapêutico , Pessoa de Meia-Idade , Suíça , Atenção Primária à Saúde/métodos , Atitude do Pessoal de Saúde , Adulto , Grupos Focais/métodos , Inquéritos e Questionários , Médicos de Atenção PrimáriaRESUMO
BACKGROUND: Co-management encompasses the dyadic process between two healthcare providers. The Provider Co-Management Index (PCMI) was initially developed as a 20-item instrument across three theory-informed subscales. OBJECTIVE: This study aimed to establish construct validity of the PCMI with a sample of primary care providers through exploratory and confirmatory factor analyses. METHODS: We conducted a cross-sectional survey of primary care physicians, nurse practitioners, and physician assistants randomly selected from the IQVIA database across New York State. Mail surveys were used to acquire a minimum of 300 responses for split sample factor analyses. The first subsample (derivation sample) was used to explore factorial structure by conducting an exploratory factor analysis. A second (validation) sample was used to confirm the emerged factorial structure using confirmatory factor analysis. We performed iterative analysis and calculated good fit indices to determine the best-fit model. RESULTS: There were 333 responses included in the analysis. Cronbach's alpha was high for a three-item per dimension scale within a one-factor model. The instrument was named PCMI-9 to indicate the shorter version length. DISCUSSION: This study established the construct validity of an instrument that scales the co-management of patients by two providers. The final instrument includes nine items on a single factor using a 4-point, Likert-type scale. Additional research is needed to establish discriminant validity.
Assuntos
Atenção Primária à Saúde , Psicometria , Humanos , Estudos Transversais , Masculino , Feminino , Reprodutibilidade dos Testes , Inquéritos e Questionários/normas , Adulto , New York , Pessoa de Meia-Idade , Atenção Primária à Saúde/normas , Atenção Primária à Saúde/métodos , Atenção Primária à Saúde/estatística & dados numéricos , Psicometria/instrumentação , Análise Fatorial , Profissionais de Enfermagem/estatística & dados numéricos , Profissionais de Enfermagem/normas , Médicos de Atenção Primária/estatística & dados numéricos , Médicos de Atenção Primária/normas , Médicos de Atenção Primária/psicologia , Pessoal de Saúde/estatística & dados numéricos , Pessoal de Saúde/psicologiaRESUMO
BACKGROUND: The use of medical health applications (mHealth apps) by patients, caregivers, and physicians is widespread. mHealth apps are often employed by physicians to quickly access professional knowledge, guide treatment, easily retrieve medical records, and monitor and manage patients. This study sought to characterize the use of mHealth apps among primary care physicians (PCPs) in Israel. The reasons for using apps and barriers to their use were also investigated. METHODS: From all MHS' PCPs, we randomly selected 700 PCPs and invited them to complete a questionnaire regarding the use of mHealth apps and attitudes toward them. RESULTS: From August 2020 to December 2020, 191 physicians completed the questionnaire (response rate 27.3%). 68.0% of PCPs reported using mHealth apps. Telemedicine service apps were the most frequently used. Medical calculators (used for clinical scoring) and differential diagnosis apps were the least frequently used. The most common reason for mHealth app use was accessibility, followed by time saved and a sense of information reliability. Among infrequent users of apps, the most common barriers reported were unfamiliarity with relevant apps and preference for using a computer. Concerns regarding information reliability were rarely reported by PCPs. Physician gender and seniority were not related to mHealth app use. Physician age was related to the use of mHealth apps. CONCLUSIONS: mHealth apps are widely used by PCPs in this study, regardless of physician gender or seniority. Information from mHealth apps is considered reliable by PCPs. The main barrier to app use is unfamiliarity with relevant apps and preference for computer use.
Assuntos
Aplicativos Móveis , Médicos de Atenção Primária , Telemedicina , Humanos , Estudos Transversais , Israel , Reprodutibilidade dos Testes , Distribuição Aleatória , População do Oriente MédioRESUMO
BACKGROUND: Many U.S. states have legislated to allow nurse practitioners (NPs) to independently prescribe drugs. Critics contend that these moves will adversely affect quality of care. OBJECTIVE: To compare rates of inappropriate prescribing among NPs and primary care physicians. DESIGN: Rates of inappropriate prescribing were calculated and compared for 23 669 NPs and 50 060 primary care physicians who wrote prescriptions for 100 or more patients per year, with adjustment for practice experience, patient volume and risk, clinical setting, year, and state. SETTING: 29 states that had granted NPs prescriptive authority by 2019. PATIENTS: Medicare Part D beneficiaries aged 65 years or older in 2013 to 2019. MEASUREMENTS: Inappropriate prescriptions, defined as drugs that typically should not be prescribed for adults aged 65 years or older, according to the American Geriatrics Society's Beers Criteria. RESULTS: Mean rates of inappropriate prescribing by NPs and primary care physicians were virtually identical (adjusted odds ratio, 0.99 [95% CI, 0.97 to 1.01]; crude rates, 1.63 vs. 1.69 per 100 prescriptions; adjusted rates, 1.66 vs. 1.68). However, NPs were overrepresented among clinicians with the highest and lowest rates of inappropriate prescribing. For both types of practitioners, discrepancies in inappropriate prescribing rates across states tended to be larger than discrepancies between these practitioners within states. LIMITATION: The Beers Criteria addresses the appropriateness of a selected subset of drugs and may not be valid in some clinical settings. CONCLUSION: Nurse practitioners were no more likely than physicians to prescribe inappropriately to older patients. Broad efforts to improve the performance of all clinicians who prescribe may be more effective than limiting independent prescriptive authority to physicians. PRIMARY FUNDING SOURCE: The Robert Wood Johnson Foundation and National Science Foundation.