Ability Of Primary Care Physicians Research Articles

The Quest for Quality: Does Network Participation Matter?

The clarion call to focus on quality of health care has been heeded by many and has led to a body of research aimed at identifying factors associated with improved quality of care.1–6 In this issue, Friedberg et al.7 explore the association between quality of care—as measured by Health Plan Employer Data and Information Set (HEDIS) indicators—and two characteristics of physician group practices. Specifically, Friedberg et al.7 examined whether HEDIS measures varied by the size of the physician group and by whether or not the physician group was a member of a “physician network”. They reviewed data from five managed care organizations that encompassed contracts with more than 4,300 primary care physicians in group practices in Massachusetts. Friedberg et al.7 found that in multivariate models, physician group size was associated with only 3 of 12 HEDIS measures. Of note, whereas for two diabetes-related HEDIS measures medium-sized groups had more favorable performance scores, for another diabetes-related HEDIS measure, small physician groups had the more favorable performance scores. The data regarding an association between network affiliation and HEDIS performance yielded more consistent results. Specifically, Freidberg et al. found that in multivariate analyses, network affiliation was associated with higher HEDIS performance scores in 8 (of 12) measures. These findings were fairly robust, overall holding up well under various conditions such as excluding the two highest performing networks from one analysis and excluding the two largest networks from another analysis. How does the examination of these organizational constructs (group size and network affiliation) contribute to our understanding of quality care and what are the policy implications of the data presented by the findings by Friedberg et al.?7 From a policy perspective, it is particularly important to consider interventions that are not just effective but are also feasible, efficient, relatively generalizable to a variety of healthcare settings. Furthermore, interventions that can be applied at the system level are attractive, as they do not rely solely on the vagaries of individual physician behavior. The analyses on group size failed to reveal a pattern that could be used to develop and test an intervention that has high potential for meeting even the fundamental policy criteria of being effective. Why? Because in their analysis, there was no preponderance of evidence that any one group size had a distinct advantage over another vis-a-vis the selected HEDIS performance measures. This is not necessarily a disappointing result. Indeed, as the ability of primary care physicians to organize themselves into medium or large group practices is likely constrained by a number of factors (geographic location, population density, etc.), the data by Friedberg et al.7 offer some comforting assurance that there are not huge missed opportunities to improve quality of care imposed by the constraints on altering group practice size. The analyses on network affiliation yielded more promising policy implications. Network affiliation was associated with improved HEDIS performance scores across a majority of measures. The policy implications are intriguing because if network affiliation is truly an important player in the causal pathway toward quality, then developing broad-based strategies to enhance physician group enrollment into networks would be feasible relatively efficiently and potentially generalizable to a variety of practice settings. Indeed, during the 1990s, there was rapid expansion of the number of physicians affiliated with networks.8 At the end of the day, however, the findings presented by Friedberg et al.7 are intriguing and provocative, but insufficient in and of themselves to be the sole impetus for sound policy development. Their findings, however, when taken into account with studies looking at the impact of other additional organizational strategies such as pay for performance9 should provide healthcare markets with sufficient information to begin to implement and test the impact of specific interventions on quality measures in a prospective manner.

Skin Cancer Prevention in the Primary Care Setting: Assessment Using a Standardized Patient

Our objective was to utilize the standardized patient technique in assessing the ability of primary care physicians to identify and counsel primary prevention for patients at high risk for skin cancer. A secondary goal was to test the feasibility of this technique as a measure of actual physician behaviors in the outpatient setting. We used a convenience sample of 15 primary care physicians. The standardized patient was an 18-year-old woman with skin phototype I. She presented to physicians as needing a general physical examination for a summer lifeguard job at a beach. She stated a family history of skin cancer. Physician performances were rated using a standard checklist completed by the standardized patient following each visit. We found that none of the physicians asked questions specifically related to skin phototype or sun exposure habits such as childhood sunburns. Only 13% asked about mole changes. For counseling, 67% of physicians recommended sunscreen use; only 7% discussed sunscreen types or procedures for effective use. Only 13% counseled other skin protective behaviors. No significant differences by physician gender were found in these areas; however, female physicians counseled more global health behaviors than male physicians (p < or = 0.01). Our pilot data suggest that little skin cancer primary prevention counseling is performed for high-risk patients. The standardized patient technique worked well in obtaining outcome data for physicians' preventive practices.

Identification and management of depression in primary care settings. A meta-review of evidence

The purpose of this review is to summarize the evidence base on the effectiveness of (a) screening for depression in primary care; (b) managing depression in primary care employing specific management strategies; (c) treating primary care depressive patients with antidepressants. Meta-review of all available reviews of the evidence. Screening alone does not improve the recognition, management and outcome of depression in primary care settings. Management strategies, including (a) training primary care staff, (b) consultation-liaison, (c) collaborative care, (d) replacement/referral are supported by insufficient evidence to provide a definite answer as to the clinical effectiveness of individual models. Robust evidence exists to encourage physicians to prescribe effective doses of antidepressants in patients with moderate to severe depression who seek treatment in primary care settings. Population-level screening campaigns have a negative ratio of costs to benefits. However, at an individual-level of care increasing the ability of primary care physicians in recognising depression remains a relevant factor. Primary care physicians should consider whether depression is mild, moderate or severe. This patient categorisation help develop appropriate management and therapeutic strategies.

Ability of primary care physician's to break bad news: A performance based assessment of an educational intervention

Objective We have previously described a breaking bad news (BBN) training program for primary care physicians [Ungar L, Alperin M, Amiel GE, Beharier Z, Reis S. Breaking bad news: structured training for family medicine residents. Patient Educ Couns 2002;48:63–68]. In this paper, we present the assessment of an educational intervention aimed at improving this important skill. Methods The assessment tool was an eight station objective structured clinical examination (OSCE) utilizing standardized patients (SPs). Intervention and control groups of 17 general practitioners (GP) each were evaluated before and after an educational intervention, or a Balint group (control). Results Intervention group GPs significantly increased their average grade on the post-test as compared to the pre-test (58.5, S.D. 12.7 versus 68.4, S.D. 9.2), effect size 0.94. Improvement in the control group was minimal (pre-test 57, S.D. 10.4 versus 58.1, S.D. 9.5 for the post-test), effect size 0.23. Reliability of the OSCE was α = 0.81. Conclusion The performance assessment used in this study proved to be a reliable and valid tool to assess the ability of physicians to break bad news. It provided evidence of the effectiveness of the intervention. Practice implications BBN training can and should be evaluated by valid and reliable measures. SPs can serve as reliable evaluators of BBN training.

Detection of somatization and depression in primary care in Saudi Arabia

Studies have shown a high worldwide prevalence of mental disorders in primary care. Many patients present with unexplained physical symptoms rather than psychological complaints, resulting in an excess number of costly clinical investigations. This study investigates the ability of primary care physicians to correctly detect and diagnose somatization and depression in Saudi Arabian patients. In all 431 primary care patients in Riyadh Saudi Arabia were screened for somatization and depression using the Patient Health Questionnaire (PHQ). Primary care physicians independently assessed these same patients while blinded to the results of the PHQ. Agreement between physician observations and the screening instrument was examined. Using the PHQ as the standard of comparison for measuring the detection rates of Saudi physicians, the agreement between and the PHQ and physician assessments was kappa = 0.40 for depression (0.45 females, 0.31 males) and kappa = 0.27 for somatization (0.36 females, 0.12 males). Physicians assessed higher rates of somatization than indicated by the screening instrument and demonstrated poor diagnostic agreement on somatization and depression, particularly for male patients. Saudi primary care physicians have awareness of psychiatric disorders, but their diagnostic skills are poor for somatization and depression. Psychiatric training should be supported in the continuing education of primary care physicians and patients should be encouraged to report psychological complaints to family physicians. A simple screening instrument for identifying mental disorders in developing countries is a valuable tool for assessment in primary care.

Intra-rator variability of primary care physicians in management of hyperlipidaemia.

Recent studies support the link between hyperlipidaemia and increased prevalence of cardiovascular diseases (CVDs). In Saudi Arabia, CVDs became a serious problem following rapid urbanization. The health care system in Saudi Arabia makes the primary care accessible to all. To assess the ability of primary care physicians to be consistent with themselves in the management of hyperlipidaemia. Cross-sectional. Family medicine department affiliated with tertiary hospital. Using 63 patient problem vignettes, each physician was asked, whether a patient required no treatment, dietary or drug treatment. Exact vignette cases were shown again to each physician two weeks later. The Kappa statistical test was used to measure the physician's intra-rator variability. Forty-seven physicians were recruited to participate in this study. The Kappa statistics suggested an excellent intra-rator agreement by only four physicians, but a large majority, 28 physicians (62.2%) had fair to good agreement while thirteen physicians (28.9%) had poor agreement with themselves. It is suggested that doctors must undergo adequate training and continuous evaluation of their skills in the management of hyperlipidaemia. Use of vignettes, might be a good method in assessing continuous medical education.

Psychiatry for Primary Care Physicians

Medical Writings15 June 1998Psychiatry for Primary Care PhysiciansAlbert Liebman, MDAlbert Liebman, MDMedical College of Wisconsin, Milwaukee, WisconsinSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-128-12_Part_1-199806150-00037 SectionsAboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Psychiatry for Primary Care Physicians; Goldman LS, Wise TN, Brody DS, eds. 389 pages. Chicago: American Med Assoc; 1998. $49.95. ISBN 0899708927. Order phone 312-464-5602.Field of medicine: Primary care.Format: Hardcover book.Audience: Primary care physicians.Purpose: To improve the ability of primary care physicians to diagnose and manage psychiatric problems in an office setting and to supply these practitioners with psychiatric information from specialty and subspecialty journals.Content: The book is organized into three sections. The first 2 chapters cover psychiatric assessment and diagnosis, and the next 12 address specific mental disorders according to DSM-IV diagnostic categories. The ... Author, Article, and Disclosure InformationAffiliations: Medical College of Wisconsin, Milwaukee, Wisconsin PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetails Metrics 15 June 1998Volume 128, Issue 12_Part_1Page: 1051KeywordsDecision makingDiagnostic and Statistical Manual of Mental Disorders fourth editionPopulation statisticsPrimary care physiciansSub-specialty care ePublished: 15 August 2000 Issue Published: 15 June 1998 Copyright & PermissionsCopyright © 1998 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...

Dealing with obesity as a chronic disease.

There are major efforts underway to educate the primary care physician about the health risks of obesity. Obesity is a chronic disease that requires chronic management. We must establish models that allow primary care physicians to participate in the chronic management of obesity, while recognizing that the interest and ability of primary care physicians to participate in obesity management will vary. Three general models of obesity management are proposed for the primary care physician, ranging from minimal evaluation to complete evaluation and treatment. In order for the models to be implemented, we must consider establishing a category of obesity specialists who can develop comprehensive treatment programs to which patients with obesity can be referred, and who can provide leadership and guidance for primary care physicians who are involved in obesity management. The North American Association for the Study of Obesity (NAASO) could help establish obesity specialists and provide a structure to allow them to provide leadership for obesity treatment.

History-taking and Preventive Medicine Skills among Primary Care Physicians: An Assessment Using Standardized Patients

Background: The ability of primary care physicians to obtain important clinical information in initial encounters with new patients is a core competency that has received little attention in previous studies. This paper describes the history-taking and preventive screening skills of practicing primary care physicians in initial interactions with ambulatory patients, as determined by a large panel of standardized patients. Methods: Standardized patient cases with diverse presentations were developed and used to assess the clinical skills of 134 primary care physicians from five Northwest states. Scoring categories for each case identified the percentage and content of essential history items and preventive screening items performed. Physicians’ scores were compared by training and practice characteristics. Results: Physicians asked 59% of essential history items. They frequently obtained appropriate information about presenting symptoms and medications, but they often missed important information about related symptoms and medical history. Physicians frequently screened for smoking and alcohol use, but rarely asked about recreational drug use. Although board-certified general internists performed more comprehensive histories than board-certified family practitioners in the same amount of time, both groups of providers missed a large number of items that should have been influential in developing diagnostic and treatment plans. Conclusions: Primary care physicians may miss important patient information in their initial interactions with patients. Medical intake questionnaires or other approaches should be considered to ensure that more complete and accurate information is available to guide diagnostic and treatment plans.

Tuberculosis

Over the past several years, the incidence of tuberculosis has dramatically increased. Complicating the rise in number of cases is the emergence of multi-drug-resistant strains of tuberculosis. In certain segments of the population, this problem has reached epidemic proportions and has taxed the resources of the health care delivery system, particularly in inner-city areas. The problem of tuberculosis has reemerged after years of relative quiescence not only because of the AIDS epidemic but also because of increased immigration from countries with uncontrolled tuberculosis. Control of the current tuberculosis problem depends not only on public health policy but also relies heavily on the ability of primary care physicians to recognize and facilitate appropriate treatment of patients with this disease to decrease morbidity, mortality, and communicability. This review will focus on practical aspects of the diagnosis and treatment of tuberculosis with particular emphasis on central nervous effects of TB infection and its treatment. The safety and efficacy of drugs recently added to the therapeutic armamentarium, as well as those that have been available for many years, will be reviewed. Last, medicolegal and ethical issues regarding tuberculosis control will be discussed.

Mental health treatment in Ontario: selected comparisons between the primary care and specialty sectors.

Epidemiologic research has demonstrated that the majority of mental illness in the community is not treated. Primary care physicians and the specialty mental health sector each have an important role in the provision of mental health services. Our goal is to clarify the extent of undertreatment of selected mental illnesses in Ontario and to examine how treatment is divided between the primary care and specialty sectors. In particular, we are interested in both the relative numbers and the types--based on sociodemographic and severity indicators--of patients found in each sector, as well as in confirming the key role of primary care in the provision of mental health services. Data were taken from the Mental Health Supplement to the Ontario Health Survey, a community survey of 9953 individuals. All subjects who met DSM-III-R criteria for a past year diagnosis of mood, anxiety, substance abuse, bulimic, or antisocial personality disorders were categorized by their use of mental health services in the preceding year--into nonusers, primary care only patients, specialty only patients, and both sector patients. The 3 groups utilizing services were then compared by demographic, clinical, and disability characteristics. Only 20.8% of subjects with a psychiatric diagnosis reported use of mental health services, but 82.9% of these same individuals used primary care physicians for general health problems. Among those who used mental health services, 38.2% used family physicians only for psychiatric treatment, compared with 35.8% who used only specialty mental health providers, and 26.0% who used both sectors. The 3 groups of users showed only modest differences on sociodemographic characteristics. Patients in the specialty only sector reported significantly higher rates of sexual and physical abuse. On specific disability measures, all 3 groups were similar. The vast majority of individuals with an untreated psychiatric disorder are using the primary care sector for general health treatment, allowing an opportunity for identification and intervention. Primary care physicians also treat the majority of those seeking mental health services, and individuals seen only by these primary care physicians are probably as ill as those seen exclusively in the specialty mental health sector. From a public health perspective, future policy interventions should aim to improve collaboration between the 2 sectors and enhance the ability of primary care physicians to deliver psychiatric services.

Quality in HIV/AIDS Care Specialty-Related or Experience-Related?

In this issue, Markson et al. describe the characteristics of New York state clinics caring for Medicaid- enrolled outpatients with a new AIDS diagnosis between 1987–92.1 Their work is interesting because these descriptions can be used to measure the process of care provided by various types of clinics. Results suggest that HIV/AIDS-dedicated and infectious disease clinics provide better care than community-based primary care clinics, which in turn provide better care than hospital-based general medicine clinics. While they did not measure clinical outcomes or the costs of care, Markson and colleagues do reference a literature that supports the connection between improved outcomes and the process of care, including for example, access to care and the availability of comprehensive services. Given these results, one might reasonably reconsider the proposition that HIV/AIDS care is best provided by generalists.2

Ability of primary care physicians to recognize physical findings associated with HIV infection: Pauuw DS, Wenrich MD, Curtis JR, et al. JAMA 1995;274:1380–1382

Ability of primary care physicians to recognize physical findings associated with HIV infection: Pauuw DS, Wenrich MD, Curtis JR, et al. JAMA 1995;274:1380–1382

Ability of Primary Care Physicians to Recognize Physical Findings Associated With HIV Infection

To assess the ability of primary care physicians to identify physical findings associated with human immunodeficiency virus (HIV) infection. Standardized patient examination. A total of 134 general internists and family practitioners were randomly selected after stratifying by year of medical school graduation, specialty, and experience caring for patients with HIV infection. Recognition of physical findings of Kaposi's sarcoma, oral hairy leukoplakia, and diffuse lymphadenopathy. Despite being directed by presenting histories to sites of prominent physical abnormalities, only 23 (25.8%) of 89 physicians evaluating a patient with Kaposi's sarcoma and 22 (22.7%) of 97 physicians evaluating a patient with oral hairy leukoplakia detected and correctly diagnosed the abnormalities. Twenty-three (17%) of 133 physicians detected diffuse lymphadenopathy in a patient complaining of fatigue, fever, and arthralgias. Physicians with the most experience treating patients with HIV infection more frequently identified oral hairy leukoplakia, but HIV experience did not influence identification of Kaposi's sarcoma or detection of lymphadenopathy. There were no differences between general internists and family practitioners or among physicians by year of medical school graduation in identifying the three physical findings associated with HIV infection. Primary care physicians may frequently miss important physical findings related to HIV infection during patient examinations.

Ability of primary care physicians to recognize physical findings associated with HIV infection

Ability of primary care physicians to recognize physical findings associated with HIV infection

Physicians' Ability to Provide Initial Primary Care to an HIV-Infected Patient

Primary care physicians are providing care for an increasing number of persons infected with the human immunodeficiency virus (HIV). This study assesses the ability of primary care physicians to provide initial care for a patient with recently diagnosed HIV infection. A standardized patient (SP) was trained to portray an asymptomatic person with HIV infection seeking a primary care physician. Physicians took a medical history and counseled the SP; their performances were assessed by the SP and through a brief written examination. In addition, physicians distributed questionnaires to HIV-infected patients in their practices to assess actual performance. The study participants consisted of 121 primary care physicians. A minority of physicians recommended standard primary care screening tests and vaccinations, including viral hepatitis screening (35%), syphilis serologic testing (32%), and pneumococcal vaccination (23%). While most physicians (87%) indicated they would obtain CD4 cell counts, only 50% indicated they would start appropriate Pneumocystis carinii pneumonia prophylaxis. Although this patient presented documentation of a positive tuberculin skin test and no prior therapy for tuberculosis, only 53% of the physicians recommended prophylactic isoniazid. While 75% of the physicians asked this SP about condom use, number of sexual partners, or contact with previous sexual partners. Physicians with the most HIV experience were more likely to recommended P carinii pneumonia prophylaxis, coinfection screening, pneumococcal vaccination, and isoniazid prophylactic therapy. However, physicians' HIV experience was not associated with assessing this SP's risk of infecting others or with counseling regarding condom use. Questionnaires distributed to HIV-infected patients of these physicians generally confirmed these findings. Basic HIV preventive and primary care may not be adequately performed by many primary care physicians. Physicians' HIV experience was associated with better performance of HIV primary care tasks, but not with screening and counseling concerning the spread of HIV infection.

The Role of the Primary Care Physician in the Care of Children with Serious Heart Disease

To determine the roles of primary care physicians and specialists in the medical care of children with serious heart disease. Pediatric Cardiology Division; Tertiary Care Children's Hospital. Convenience sample of parents, primary care physicians, and pediatric cardiologists of 92 children with serious heart disease. Questionnaire study; questionnaires based on 16 medical care needs, encompassing basic primary care services, care specific to the child's heart disease and general issues related to chronic illness. All children had a primary care physician (PCP), and both they and the parents (P) reported high utilization of PCP for basic primary care services. However, there was little involvement of PCP in providing care for virtually any aspect of the child's heart disease. Parents expressed a low level of confidence in the ability of PCP in general or their child's own PCP to meet many of their child's medical care needs. Both PCP and pediatric cardiologists (PC) were significantly more likely than parents to see a role for PCP in providing for care specific to the heart disease as well as more general issues related to chronic illness. PC and PCP generally agreed about the role PCP should play, although PC saw a bigger role for PCP in providing advice about the child's activity than PCP themselves did. PC were less likely to see the PCP as able to follow the child for long term complications than PCP did. PC were more likely than PCP to believe that PCP were too busy or were inadequately reimbursed to care for children with serious heart disease. Only about one-third of parents reported discussing psychosocial, family, economic, or genetic issues with any provider, and PCP were rarely involved in these aspects of chronic illness. Primary care physicians do not take an active role in managing either the condition-specific or the more general aspects of this serious chronic childhood illness. With appropriate information and support from their specialist colleagues primary care physicians could provide much of the care for this group of children. Generalists and specialists are both responsible for educating and influencing parents about the role primary care physicians can play in caring for children with serious chronic illness.

Diagnostic Agreement between Primary Care Physicians and Neurologists

The ability of primary care physicians (PCPs) to diagnose neurologic disorders was assessed from the records of 166 patients referred to the neurology outpatient clinic in one year. At the time of referral, 74.7% were correctly diagnosed. Primary care physicians were competent in the diagnosis of cerebrovascular accidents, epilepsy, space-occupying lesions, dementia, extrapyramidal and cerebellar disorders. More specific diagnosis was difficult at the primary care level in cases of headache, spinal cord and peripheral nerve disorders. The implications of these results and possible reasons for them are discussed. Solutions to improve on this situation are recommended with emphasis on both undergraduate and postgraduate training in neurological bedside skills. The complementary roles of the primary care physician and the neurologist are stressed.

Physicians’ Attitudes Toward Preventive Care Services: A Seven-Year Prospective Cohort Study

We report results of a seven-year prospective cohort study of physicians' attitudes about and intentions to provide 27 preventive care services in their future practices. Respondents in the cohort were surveyed three times: first, during orientation to medical school; second, during their third year of medical school; and finally, following completion of their third-year of residency training. The majority of preventive care services were viewed as more important to clinical practice in primary care than in non-primary care specialties. Positive attitudes toward preventive care services generally persisted among both primary and non-primary care physicians. Respondents expressed only fair to medium levels of confidence in the ability of physicians in their specialty areas to provide any of the preventive services examined. Respondents reported low levels of confidence in the ability of primary care physicians to provide nutritional counseling, though they ranked it as important. Respondents were fairly or moderately confident in the ability of primary care physicians to provide counseling about smoking cessation, health, AIDS education, and substance abuse. Participants ranked smoking cessation counseling, health counseling, AIDS education, cancer detection education, and substance abuse counseling and education as very important. In general, physicians were less likely to plan on providing preventive services than they were to expect their residency programs to prepare most or all to provide the services. Findings document the need to prepare physicians better to provide preventive services.

Genetic Diagnosis: Implications for Medical Practice

Genetic diagnostic techniques increasingly permit the detection of predisposition to illness long before the onset of the disease process itself. Medicine is on the verge of becoming a predictive science as well as a diagnostic and therapeutic one. Genetic diagnosis could have profound effects on many aspects of our health care system, including the prestige and effectiveness of preventive medicine, the competitive behavior of health care organizations and insurance companies, access to private health insurance, the ability of primary care physicians to serve as gatekeepers, and other matters. This article examines the range of potential effects of the new genetic diagnostics on the organization and financing of health care. For purposes of illustration the authors examine in detail the possible consequences of genetic tests for predisposition to two diseases: Reye's Syndrome and lung cancer in smokers.