Patients report better satisfaction with part-time primary care physicians, despite less continuity of care and access.

BACKGROUND: The growing number of primary care physicians (PCPs) reducing their clinical work hours has raised concerns about meeting the future demand for services and fulfilling the continuity and access mandates for patient-centered care. However, the patient's experience of care with part-time physicians is relatively unknown, and may be mediated by continuity and access to care outcomes. OBJECTIVE: We aimed to examine the relationships between a physicians' clinical full-time equivalent (FTE), continuity of care, access to care, and patient satisfaction with the physician. DESIGN: We used a multi-level structural equation estimation, with continuity and access modeled as mediators, for a cross-section in 2010. PARTICIPANTS: The study included family medicine (n = 104) and internal medicine (n = 101) physicians in a multi-specialty group practice, along with their patient satisfaction survey responses (n = 12,688). MAIN MEASURES: Physician level FTE, continuity of care received by patients, continuity of care provided by physician, and a Press Ganey patient satisfaction with the physician score, on a 0-100 % scale, were measured. Access to care was measured as days to the third next-available appointment. KEY RESULTS: Physician FTE was directly associated with better continuity of care received (0.172% per FTE, p < 0.001), better continuity of care provided (0.108% per FTE, p < 0.001), and better access to care (-0.033 days per FTE, p < 0.01), but worse patient satisfaction scores (-0.080% per FTE, p = 0.03). The continuity of care provided was a significant mediator (0.016% per FTE, p < 0.01) of the relationship between FTE and patient satisfaction; but overall, reduced clinical work hours were associated with better patient satisfaction (-0.053 % per FTE, p = 0.03). CONCLUSIONS: These results suggest that PCPs who choose to work fewer clinical hours may have worse continuity and access, but they may provide a better patient experience. Physician workforce planning should consider these care attributes when considering the role of part-time PCPs in practice redesign efforts and initiatives to meet the demand for primary care services.

Patients' body mass index and blood pressure over time: diagnoses, treatments, and the effects of comorbidities.

BACKGROUND: A national strategic framework to address multiple chronic conditions has called for further research on disease trajectories of patients with comorbidities. METHODS: An observational study using multilevel models to analyze electronic health record data from a multispecialty practice from 2003 to 2010 to examine disease trajectories of patients with at least 2 of 3 common chronic conditions: overweight/obese, hypertension, and depression. Using longitudinal data on up to 110,000 patients, the effects of comorbidities on the probability of having a diagnosis for overweight/obesity or hypertension and on the trajectories of body mass index (BMI) and blood pressure (BP) over time were examined. RESULTS: From 2003 to 2010, the percentage of patients with high BMI receiving an overweight/obesity diagnosis grew from 5.0% to 18.7%, and the percentage of patients with high BP having a hypertension diagnosis rose from 39.9% to 51.7%. The effect of time for patients with high BMI and depression was less than the effect of time for high BMI only patients (P<0.01) in receiving overweight/obesity diagnoses. Co-occurring depression and high BMI was positively associated with BMI trajectory (coefficient=0.06, P<0.01), whereas high BP and high BMI (coefficient=-0.07, P<0.01) or high BP and high BMI and depression (coefficient=-0.05, P<0.01) were negatively associated with BMI trajectories. CONCLUSIONS: Although physicians' recording of diagnoses for patients with high BMI and high BP has improved, significant gaps remain. Some co-occurrence patterns of these 3 conditions not only affected the recognition of overweight/obesity and hypertension over time, but also BMI trajectories over time. Quality improvement efforts should target patients with co-occurring depression and overweight/obesity.

Value of Adherence to Posttreatment Follow-Up Guidelines for Head and Neck Squamous Cell Carcinoma.

OBJECTIVES: The utility of intensive posttreatment surveillance of head and neck squamous cell carcinoma (HNSCC) has been debated. The objective is to investigate adherence to the National Comprehensive Cancer Network (NCCN) posttreatment follow-up guidelines and assess the association with recurrence and survival. METHODS: A total of 452 patients diagnosed with HNSCC at an academic medical center in a socioeconomically disadvantaged, urban setting were categorized by adherence to NCCN follow-up guidelines. Survival analyses were conducted to study the association between adherence and the 5-year overall survival and disease-specific survival in the entire cohort and subset of patients with documented recurrence. RESULTS: We found that 23.5% of patients were adherent to NCCN follow-up guidelines in the first year after treatment, and 15.9% were adherent over 5 years. Adherence in the first year was significantly associated with 5-year overall survival (HR 0.634; 95% CI 0.443-0.906; p = 0.0124) and disease-specific survival (HR 0.556; 95% CI 0.312-0.992; p = 0.0470), but consistent adherence over 5 years did not show a significant association. Among the 21.7% of the cohort with recurrence, adherence was not associated with early-stage recurrence (AJCC stage I/II). In this subset, first year adherence was associated with improved disease-specific but not overall survival, and adherence over 5 years was not associated with survival. CONCLUSION: Adherence to NCCN follow-up guidelines in the first year after treatment was associated with a better chance of 5-year overall and disease-specific survival, but this significant association was not observed among those who demonstrated consistent adherence over 5 years. LEVEL OF EVIDENCE: 3 Laryngoscope, 134:708-716, 2024.

Development and Interrater Agreement of a Novel Classification System Combining Medical and Surgical Adverse Event Reporting.

Importance: Categorization systems for adverse events are not standardized across care settings and specialties and do not always include near miss events (events where there was potential for patient harm, but where no actual harm occurred), making it difficult to effectively assess patient safety for quality improvement. Objective: To develop and assess interrater agreement on a classification system for adverse events reporting that incorporates events in both inpatient and outpatient settings across medical and surgical subspecialties including near miss events. Design, Setting, and Participants: A cross-sectional study in a tertiary care center including 174 patient cases occurring from 2018 to 2020 was carried out. Data were abstracted from a Department of Otorhinolaryngology-Head and Neck Surgery Quality Assurance database. The cases were comprised of near miss and adverse events occurring in adult and pediatric patients in inpatient, outpatient, and emergency department settings. The ratings took place in March and April of 2022. Exposures: Four raters (2 attending physicians and 2 senior resident physicians) were recruited to classify these cases according to 3 classification systems: the National Coordinating Council for Medication Error Reporting and Prevention (NCC-MERP), Clavien-Dindo, and our novel Quality Improvement Classification System (QICS). Main Outcomes and Measures: The primary outcome was overall interrater agreements using Fleiss κ. Results: Across all 4 raters grading 174 cases, the NCC-MERP, Clavien-Dindo, and QICS received a κ score. Fair-to-moderate interrater reliability was observed between the resident and attending physician groups across the 3 classification systems: NCC-MERP (κ = 0.33; 95% CI, 0.30-0.35), Clavien-Dindo (κ = 0.47; 95% CI, 0.43-0.50), and QICS (κ = 0.42; 95% CI, 0.39-0.44). Strong interrater concordance was observed for complications across all scenarios. Conclusion and Relevance: This cross-sectional study found that the new QICS classification scheme was applicable to wide-ranging clinical scenarios with a focus on patient-centered outcomes including near miss events. In addition, QICS allowed for the comparison of patient outcome data in a multitude of settings.

False lithium toxicity secondary to lithium heparin test tube: A case report and review.

This case demonstrates a false elevation of serum lithium concentrations that can occur when blood samples are collected using lithium heparin (green-top) tubes. The patient was a 58-year-old female on chronic lithium therapy for bipolar disorder who presented to the emergency department following an overdose of 5 unidentified medications. The patient was overly sedated and exhibited paradoxical laughter, slurred speech, and mild abdominal pain. The recommended maintenance lithium concentration is 0.6 to 1.0 mmol/L, and she had previously been stable within this therapeutic range. The initial lithium concentration drawn upon admission was 2.05 mmol/L. No intervening treatment was made with the exception of intravenous fluids due to a lack of correlation between clinical presentation and the lithium concentration. Six hours later, a repeat lithium concentration of <0.10 mmol/L was obtained. Upon investigation, it was discovered that the initial blood sample was obtained in a lithium heparin green-top tube instead of the recommended plastic tubes with either sodium heparin or dipotassium ethylenediamine tetraacetic acid as the anticoagulant. As this case demonstrates, lithium heparin tubes have the potential to cause falsely elevated lithium concentrations. It is important for health care professionals to be aware of the false elevations that can occur when blood samples are taken in this type of tube.

Reliability, Validity, and Responsiveness of the Mini-Balance Evaluation Systems Test in Ambulatory Individuals with Multiple Sclerosis.

Purpose: The purpose of this study was to determine the reliability, validity, and responsiveness of the Mini-Balance Evaluation Systems Test (MBT) in persons with multiple sclerosis (pwMS). Method: A total of 32 pwMS completed a questionnaire on disease severity, the Activities-specific Balance Confidence Scale (ABC), and the MBT. The MBT was re-administered 1 week later. Results: The interrater and test-retest reliability of the total MBT and subscales were excellent. The standard error of measurement for the total MBT, calculated from test-retest and interrater reliability, respectively, was 1.32 and 1.07. The minimal detectable change (MDC) for the total MBT was 3.74; the MDC for the subscales ranged from 0.98 (sensory) to 2.38 (gait). The correlations between individual subscale scores and the total MBT, among subscales, and between the total MBT and disease severity and ABC were excellent. Correlations between the total MBT and age, MS type, and fall and imbalance histories were moderate. Disease severity and ABC scores were the strongest predictors of MBT score. No floor effects were found. Ceiling effects were found for two subscales, but not for the total MBT. Conclusions: The MBT is reliable and valid in pwMS. MDC values will facilitate assessing the effectiveness of treatment. Because ceiling effects were found for two subscales, but not the total MBT, it is recommended that clinicians administer the MBT in its entirety.

Objectif : déterminer la fiabilité, la validité et la réactivité du mini-test des systèmes d'évaluation de l'équilibre (MBT) chez les personnes atteintes de sclérose en plaques (paSP). Méthodologie : au total, 32 paSP ont rempli un questionnaire sur la gravité de la maladie, l'échelle de confiance de l'équilibre lors des activités (ABC) et le MBT. Ils ont refait le MBT une semaine plus tard. Résultats : les chercheurs ont constaté une excellente fiabilité interévaluateur et test­retest du total de MBT et des sous-échelles. L'écart-type de la mesure de MBT total était de 1,32 et de 1,07, calculé à partir de la fiabilité test­retest et interévaluateur, respectivement. Le changement minimal décelable (CMD) du MBT total était de 3,74; les sous-échelles variaient entre 0,98 (expérience sensorielle) et 2,38 (démarche). Les corrélations étaient excellentes entre les scores des échelles individuelles et le total du MBT, entre les sous-échelles ainsi qu'entre le total du MBT, la gravité de la maladie et l'ABC. Celles entre le total du MBT et l'âge, le type de SP et les antécédents de chutes et de déséquilibres étaient modérées. La gravité de la maladie et les scores d'ABC étaient les prédicteurs les plus solides du score de MBT. Les chercheurs n'ont constaté aucun effet de plancher, mais des effets de plafonnement dans deux sous-échelles, sans inclure le total du MBT. Conclusions : Le MBT est fiable et valide chez les paSP. Les valeurs de CMD faciliteront l'efficacité du traitement. Compte tenu des effets de plafonnement de deux sous-échelles, mais pas du total du MBT, il est recommandé aux cliniciens d'effectuer l'intégralité du MBT.

Periodic health examinations and missed opportunities among patients likely needing mental health care.

OBJECTIVES: Periodic health examinations (PHEs) are the most common reason adults see primary care providers. It is unknown if PHEs serve as a "safe portal" for patients with mental health needs to initiate care. We examined how physician communication styles impact mental health service delivery in PHEs. STUDY DESIGN: Retrospective observational study using audio-recordings of 255 PHEs with patients likely to need mental health care. METHODS: Mixed-methods examined the timing of a mental health discussion (MHD), its quality, and the relationship between MHD quality and physician practice styles. MHD quality was measured against evidence-based practices as a 3-level variable (evidence-based, perfunctory, or absent). Physician practice styles were measured by: visit length, verbal dominance, and elicitation of a patient's agenda. A generalized ordered logit model was used. RESULTS: Many patients came with mental health concerns, as over 50% of the MHDs occurred in the first 5 minutes of the visit. One-third of the 255 patients had an evidence-based MHD, another third had a perfunctory MHD, and the remaining had no MHD. MHD quality was significantly associated with physician communication styles. Visits with physicians who tend to spend more time with patients, fully elicit patients' agendas, and let patients talk (instead of being verbally dominant) were more likely to deliver evidence-based MHD. CONCLUSIONS: If done well, PHEs could be a safe portal for patients to seek mental health care, but most PHEs fell short. Improving PHE quality may require reimbursement for longer visits and coaching for physicians to more fully elicit patients' agendas and to listen more attentively.

Effects of a dedicated regional psychiatric emergency service on boarding of psychiatric patients in area emergency departments.

INTRODUCTION: Mental health patients boarding for long hours, even days, in United States emergency departments (EDs) awaiting transfer for psychiatric services has become a considerable and widespread problem. Past studies have shown average boarding times ranging from 6.8 hours to 34 hours. Most proposed solutions to this issue have focused solely on increasing available inpatient psychiatric hospital beds, rather than considering alternative emergency care designs that could provide prompt access to treatment and might reduce the need for many hospitalizations. One suggested option has been the "regional dedicated emergency psychiatric facility," which serves to evaluate and treat all mental health patients for a given area, and can accept direct transfers from other EDs. This study sought to assess the effects of a regional dedicated emergency psychiatric facility design known at the "Alameda Model" on boarding times and hospitalization rates for psychiatric patients in area EDs. METHODS: Over a 30-day period beginning in January 2013, 5 community hospitals in Alameda County, California, tracked all ED patients on involuntary mental health holds to determine boarding time, defined as the difference between when they were deemed stable for psychiatric disposition and the time they were discharged from the ED for transfer to the regional psychiatric emergency service. Patients were also followed to determine the percentage admitted to inpatient psychiatric units after evaluation and treatment in the psychiatric emergency service. RESULTS: In a total sample of 144 patients, the average boarding time was approximately 1 hour and 48 minutes. Only 24.8% were admitted for inpatient psychiatric hospitalization from the psychiatric emergency service. CONCLUSION: The results of this study indicate that the Alameda Model of transferring patients from general hospital EDs to a regional psychiatric emergency service reduced the length of boarding times for patients awaiting psychiatric care by over 80% versus comparable state ED averages. Additionally, the psychiatric emergency service can provide assessment and treatment that may stabilize over 75% of the crisis mental health population at this level of care, thus dramatically alleviating the demand for inpatient psychiatric beds. The improved, timely access to care, along with the savings from reduced boarding times and hospitalization costs, may well justify the costs of a regional psychiatric emergency service in appropriate systems.

Leveraging electronic health records to develop measurements for processes of care.

OBJECTIVES: To assess the reliability of data in electronic health records (EHRs) for measuring processes of care among primary care physicians (PCPs) and examine the relationship between these measures and clinical outcomes. DATA SOURCES/STUDY SETTING: EHR data from 15,370 patients with diabetes, 49,561 with hypertension, in a group practice serving four Northern California counties. STUDY DESIGN/METHODS: Exploratory factor analysis (EFA) and multilevel analyses of the relationships between processes of care variables and factor scales with control of hemoglobin A1c, blood pressure (BP), and low density lipoprotein (LDL) among patients with diabetes and BP among patients with hypertension. PRINCIPAL FINDINGS: Volume of e-messages, number of days to the third-next-available appointment, and team communication emerged as reliable factors of PCP processes of care in EFA (Cronbach's alpha=0.73, 0.62, and 0.91). Volume of e-messages was associated with higher odds of LDL control (≤100) (OR=1.13, p<.05) among patients with diabetes. Frequent in-person visits were associated with better BP (OR=1.02, p<.01) and LDL control (OR=1.01, p<.01) among patients with diabetes, and better BP control (OR=1.04, p<.01) among patients with hypertension. CONCLUSIONS: The EHR offers process of care measures which can augment patient-reported measures of patient-centeredness. Two of them are significantly associated with clinical outcomes. Future research should examine their association with additional outcomes.

Impact of the mental healthcare delivery system on california emergency departments.

INTRODUCTION: This is an observational study of emergency departments (ED) in California to identify factors related to the magnitude of ED utilization by patients with mental health needs. METHODS: In 2010, an online survey was administered to ED directors in California querying them about factors related to the evaluation, timeliness to appropriate psychiatric treatment, and disposition of patients presenting to EDs with psychiatric complaints. RESULTS: One hundred twenty-three ED directors from 42 of California's 58 counties responded to the survey. The mean number of hours it took for psychiatric evaluations to be completed in the ED, from the time referral was placed to completed evaluation, was 5.97 hours (95% confidence interval [CI], 4.82-7.13). The average wait time for adult patients with a primary psychiatric diagnosis in the ED, once the decision to admit was made until placement into an inpatient psychiatric bed or transfer to an appropriate level of care, was 10.05 hours (95% CI, 8.69-11.52). The average wait time for pediatric patients with a primary psychiatric diagnosis was 12.97 hours (95% CI, 11.16-14.77). The most common reason reported for extended ED stays for this patient population was lack of inpatient psychiatric beds. CONCLUSION: The extraordinary wait times for patients with mental illness in the ED, as well as the lack of resources available to EDs for effectively treating and appropriately placing these patients, indicate the existence of a mental health system in California that prevents patients in acute need of psychiatric treatment from getting it at the right time, in the right place.

Three types of ambiguity in coding empathic interactions in primary care visits: implications for research and practice.

OBJECTIVE: To describe three methodological challenges experienced in studying patients' expressions of emotion in a sample of periodic health exams, and the research and practice implications of these challenges. METHODS: Qualitative analysis of empathic cues in audio-taped and transcribed periodic health examinations of adult patients (n=322) in an integrated delivery system. The empathic and potential empathic opportunities methodology was used. RESULTS: Identifying emotional cues that constitute "empathic opportunities" is a complex task. Three types of ambiguity made this task particularly challenging: 1) presentations of emotional cues can be "fuzzy" and varied; 2) expressions of illness can be emotionally laden in the absence of explicit "emotion words"; and 3) empathic opportunities vary in length and intensity. CONCLUSION: Interactional ambiguities pose a challenge to researchers attempting to document emotional cues with a binary coding scheme that indicates only whether an empathic opportunity is present or absent. Additional efforts to refine the methodological approach for studying empathy in medical interactions are needed. PRACTICE IMPLICATIONS: The challenges discussed likely represent the same types of situations physicians find themselves in when talking with patients. Highlighting these ambiguities may aid physicians in better recognizing and meeting the emotional needs of their patients.