Challenges and Strategies for Patient Safety in Primary Care: A Qualitative Study.

Although most health care occurs in the ambulatory setting, limited research examines how providers and patients think about and enact ambulatory patient safety. This multimethod qualitative study seeks to identify perceived challenges and strategies to improve ambulatory safety from the perspectives of clinicians, staff, and patients. Data included interviews (N = 101), focus groups (N = 65), and observations of safety processes (N = 79) collected from 10 patient-centered medical homes. Key safety issues included the lack of interoperability among health information systems, clinician-patient communication failures, and challenges with medication reconciliation. Commonly cited safety strategies leveraged health information systems or involved dedicated resources (eg, providing access to social workers). Patients also identified strategies not mentioned by clinicians, emphasizing the need for their involvement in developing safety solutions. This work provides insight into safety issues of greatest concern to clinicians, staff, and patients and strategies to improve safety in the ambulatory setting.

Patient perceptions of safety in primary care: a qualitative study to inform care.

Patients' perspectives on patient safety have rarely been incorporated into quality initiatives in primary care. Our objective was to understand the patient perspective on patient safety in patient-centered medical homes (PCMHs). We conducted 12 patient focus groups/interviews in nine sites with 65 patients at a geographically diverse sample of National Committee on Quality Assurance Level 3 recognized PCMHs across three states. Using a patient safety framework, we coded and analyzed interviews for overarching themes and subthemes across patient safety domains. Overarching themes focused on (1) both clear and timely communication with and between clinicians and (2) trust in the care team, including being heard, respected, and treated as a whole person. Other themes important to specific patient safety domains included sharing of and access to information, patient education and patient-centered medication reconciliation process, clear documentation for the diagnostic process, patient-centered comprehensive visits, and timeliness of care. Communication and trust are key to patient perceptions of safe primary care. Focusing on these themes across safety domains may help to make primary care both more patient-centered and safer, and should be considered in future ambulatory safety initiatives.

Implementation of Patient Safety Structures and Processes in the Patient-Centered Medical Home.

ABSTRACT: Although most patient-clinician interactions occur in ambulatory care, little research has addressed measuring ambulatory patient safety or how primary care redesign such as the patient-centered medical home (PCMH) addresses patient safety. Our objectives were to identify PCMH standards relevant to patient safety, construct a measure of patient safety activity implementation, and examine differences in adoptions of these activities by practice and community characteristics. Using a consensus process, we selected elements among a widely adopted, nationally representative PCMH program representing activities that, according to a physician panel, represented patient safety overall and in four domains (diagnosis, treatment delays, medications, and communication and coordination) and generated a score for each. We then evaluated this score among 5,007 practices with the highest PCMH recognition level. Implementation of patient safety activities varied; the few military practices (2.4%) had the highest, and community clinics the lowest, patient safety score, both overall (82.0 and 72.0, respectively, p < .001) and across specific domains. Other practice and community characteristics were not associated with the patient safety score. Understanding better what factors are associated with implementation of patient safety activities may be a key step in improving ambulatory patient safety.

Model Homes: Evaluating Approaches to Patient-centered Medical Home Implementation.

BACKGROUND: The patient-centered medical home (PCMH) model has been widely adopted, but the evidence on its effectiveness remains mixed. One potential explanation for these mixed findings is variation in how the model is implemented by practices. OBJECTIVE: To identify the impact of different approaches to PCMH adoption on health care utilization in a long-term, geographically diverse sample of patients. DESIGN: Difference-in-differences evaluation of PCMH impact on cost and utilization. SUBJECTS: A total of 5,314,284 patient-year observations from the HealthCore Integrated Research Database, and 5943 practices which adopted the PCMH model in 14 states between 2011 and 2015. INTERVENTION: PCMH adoption, as defined by the National Committee for Quality Assurance. MEASUREMENTS: Six claims-based utilization measures, plus total health care expenditures. We employ hierarchical clustering to organize practices into groups based on their PCMH capabilities, then use generalized difference-in-differences models with practice or patient fixed effects to estimate the effect of PCMH recognition (overall and separately by the groups identified by the clustering algorithm) on utilization. RESULTS: PCMH adoption was associated with a >8% reduction in total expenditures. We find significant reductions in emergency department utilization and outpatient care, and both lab and imaging services. In our by-group results we find that while the reduction in outpatient care is significant across all 3 groups, the reduction in emergency department utilization is driven entirely by 1 group with enhanced electronic communications. CONCLUSION: The PCMH model has significant impact on patterns of health care utilization, especially when heterogeneity in implementation is accounted for in program evaluation.

Patient Safety in Primary Care: Conceptual Meanings to the Health Care Team and Patients.

INTRODUCTION: Patient safety in primary care is an emerging priority, and experts have highlighted medications, diagnoses, transitions, referrals, and testing as key safety domains. This study aimed to (1) describe how frontline clinicians, administrators, and staff conceptualize patient safety in primary care; and (2) compare and contrast these conceptual meanings from the patient's perspective. METHODS: We conducted interviews with 101 frontline clinicians, administrators and staff, and focus groups with 65 adult patients at 10 patient-centered medical homes. We used thematic analysis to approach coding. RESULTS: Findings indicate that frontline personnel conceptualized patient safety more in terms of work functions, which reflect the grouping of tasks or responsibilities to guide how care is being delivered. Frontline personnel and patients conceptualized patient safety in largely consistent ways. DISCUSSION: Function-based conceptualizations of patient safety in primary care may better reflect frontline personnel and patients' experiences than domain-based conceptualizations, which are favored by experts.

Access to and Engagement in Substance Use Disorder Treatment Over Time.

OBJECTIVE: This study evaluated whether access to and engagement in substance use disorder treatment has improved from 2010 to 2016. METHODS: Data submitted by commercial and Medicaid health plans, representing over 163 million beneficiaries from 2010 to 2016, were analyzed. RESULTS: For commercial plans, identification increased (from 1.0% to 1.6%, p<0.001), the initiation rate declined (from 41.9% to 33.7%, p<0.001), and the engagement rate also declined (from 15.8% to 12.1%, p<0.001). The decline in the initiation and engagement rates could not be explained by the increasing identification rates. For Medicaid plans, the identification rate increased (from 3.3% to 6.7%, p<0.001), and the initiation and engagement rates were unchanged. CONCLUSIONS: Although an increasing proportion of health plan members are being identified with substance use disorders, the majority of these individuals are not engaging in treatment.

Test-Retest Reliability of the King-Devick Test in an Adolescent Population.

CONTEXT: The King-Devick (KD) test is a screening tool designed to assess cognitive visual impairments, namely saccadic rhythm, postconcussion. Test-retest reliability of the KD in a healthy adolescent population has not yet been established. OBJECTIVE: To investigate the overall test-retest reliability of the KD among a sample of healthy adolescents. Additionally, we sought to determine if sex and age influenced reliability. DESIGN: Cross-sectional study. SETTING: Secondary school. PATIENTS OR OTHER PARTICIPANTS: Sixty-eight healthy adolescents, 41 boys (age = 15.4 ± 1.9 years) and 27 girls (age = 15.4 ± 1.9 years). MAIN OUTCOME MEASURE(S): Participants completed the KD (version 1) at 3 testing sessions (days 1, 30, and 45) following standard instructions. We recorded total time to complete the reading of 3 cards for each participant during each testing session. Two-way random-effects intraclass correlation coefficients (ICCs) using single measurements repeated over time and repeatability coefficients were calculated. Linear mixed models were used to determine whether differences existed at each testing time and to examine whether changes that took place among visits were different by sex or age. RESULTS: Adolescents who completed the KD demonstrated acceptable reliability (ICC = 0.81; 95% confidence interval = 0.73, 0.87); however, the repeatability coefficient was large (±8.76 seconds). The sample demonstrated improvements between visits 1 and 2 (mean ± standard error = 4.3 ± 0.5 seconds, P < .001) and between visits 2 and 3 (2.4 ± 0.5 seconds, P < .001) for a total improvement of 6.9 seconds over 3 tests. No significant visit-by-sex or visit-by-age interactions were observed. CONCLUSIONS: Despite the ICC being clinically acceptable, providers using the KD test for serial assessment of concussion in adolescents should be cautious in interpreting the results due to a large learning effect. Incorporating multiple measures can ensure accurate detection of sport concussion.

Shortening a Patient Experiences Survey for Medical Homes.

The Consumer Assessment of Healthcare Providers and Systems-Patient-Centered Medical Home (CAHPS PCMH) Survey assesses patient experiences reflecting domains of care related to general patient experience (access to care, communication with providers, office staff interaction, provider rating) and PCMH-specific aspects of patient care (comprehensiveness of care, self-management support, shared decision making). The current work compares psychometric properties of the current survey and a proposed shortened version of the survey (from 52 to 26 adult survey items, from 66 to 31 child survey items). The revisions were based on initial psychometric analysis and stakeholder input regarding survey length concerns. A total of 268 practices voluntarily submitted adult surveys and 58 submitted child survey data to the National Committee for Quality Assurance in 2013. Mean unadjusted scores, practice-level item and composite reliability, and item-to-scale correlations were calculated. Results show that the shorter adult survey has lower reliability, but still it still meets general definitions of a sound survey for the adult version, and resulted in few changes to mean scores. The impact was more problematic for the pediatric version. Further testing is needed to investigate approaches to improving survey response and the relevance of survey items in informing quality improvement.