Group Practice Setting Research Articles

Impact of an opioid risk reduction initiative on motor vehicle crash risk among chronic opioid therapy patients.

Although prescription opioids have been associated with higher motor vehicle crash (MVC) risk, it is unknown whether health system initiatives to better manage chronic opioid therapy (COT) can reduce MVC risk at the population level. We conducted an interrupted time series population-level cohort study at Group Health (GH), between January 2006 and September 2014, comparing MVC risk among COT patients who were GH members receiving care in either group practice or contracted care settings. Group practice COT risk reduction initiatives were implemented in two phases: (1) altered prescribing expectations and (2) multifaceted initiatives. These initiatives did not exist in the contracted care network. We compared the adjusted quarterly rate of MVC between group practice and contracted care patients over time using a modified Poisson regression model for a binary outcome. A total of 32 691 COT patients (27.4% from contracted care) met eligibility criteria and experienced a total of 1956 MVCs during study follow-up (mean, 8.1 quarters per person), of which 810 were serious injury crashes. Crash rates were not significantly different between the patient groups within any of the time periods. Analyses stratified by concurrent prescription of a sedative hypnotic or benzodiazepine found no significant difference between the group practice and contracted care patients. There was a modest elevation of MVC risk for high-dose patients relative to former COT patients who stopped receiving opioids. The risk of MVC was not mitigated in a large cohort of COT patients exposed to a health plan policy initiative that substantially lowered mean opioid dose. Copyright © 2016 John Wiley & Sons, Ltd.

Canadian Optometric Low Vision: Predictive Factors and Regional Comparisons

Purpose: To investigate the regional differences in low vision (LV) provision across Canada and to identify predictive factors for the provision of more extensive low vision services (LVS).
 Methods: Practising optometrists across Canada were invited to participate in a questionnaire that investigated personal and practice demographics, levels of LVS offered, patterns of referrals and barriers to provision of LVS.
 Results: 459 optometrists responded. Predictive factors for providing more extensive LVS included: optometrists with >15 years of practice, having a local LV optometrist/ophthalmologist within one day’s travel, not having a multi-disciplinary LV clinic within one-day’s travel, working in a practice in a population of <50,000, and having 2+ optometrists in the same practice. Regional differences were found in the following variables: the presence of an optometrist offering LVS within the respondent’s primary practice, referral criteria, the type of LV provider receiving the referral, and the perceived quality of LVS.
 Conclusions: LVS are provided differently across Canada and the availability of government-funded LVS appeared to enhance optometric referrals to multidisciplinary low vision clinics. Optometrists who were in a group practice setting, who had practiced for >15 years and who worked in a less populated area were more likely to provide more extensive LVS.

Current Practice Patterns Among Members of the American Urological Association for Male Genitourinary Lichen Sclerosus

To determine the practice patterns of urologists who treat male genitourinary lichen sclerosus (MGU-LS) via a national web-based survey distributed to American Urological Association members. A 20-question survey was collected from a random sample of American Urological Association members. Respondents answered questions on their practice patterns for MGU-LS diagnosis, treatment of symptomatic urethral stricture disease, surveillance, and follow-up. In total, 309 urologists completed the survey. The majority of respondents reported practicing more than 20+ years (37.5%) within an academic (31.7%) or group practice (31.1%) setting. The majority of respondents saw 3-5 men with MGU-LS per year (32.7%). The most common locations of MGU-LS involvement included the glans penis (66.2%), foreskin (26.3%), and/or the urethra (5.8%). Respondent first-line treatment for urethral stricture disease was direct visual internal urethrotomy (26.6%) and second-line treatment was referral to subspecialist (38.4%). After controlling for the number of patients evaluated with MGU-LS per year, those with reconstructive training were more likely to perform a primary urethroplasty for men with symptomatic urethral stricture disease (adjusted odds ratio 13.1, 95% confidence interval 5.1-33.8, P < .001). They were also more likely to counsel men on the associated penile cancer risks (adjusted odds ratio 4.6, 95% confidence interval 1.7-12.5, P < .01). Reconstructive urologists evaluate the most number of patients with MGU-LS and are more likely to perform primary urethroplasty for urethral stricture disease. Men with MGU-LS should be referred to a reconstructive urologist to understand the full gamut of treatment options.

Physician Group Practice Trends: A Comprehensive Review

Physician group practices in the U.S. have grown and changed significantly in terms of health professional team composition, employment contract types, ownership type, size, and management in the last 20 years. In the past, physicians were largely selfemployed or part of small practices, however today's physicians are employed by large healthcare organizations, as well as integrated delivery systems.1 Between the years of 1996-1997 and 2004-2005, the proportion of physicians in solo and two-physician practices has decreased significantly from 40.7 percent to 32.5 percent.2 Today, most physicians work in the group practice setting in the United States. Moreover, physicians are increasingly practicing in mid-sized, single-specialty groups.

The Impact of Opioid Risk Reduction Initiatives on High-Dose Opioid Prescribing for Patients on Chronic Opioid Therapy

Avoiding high opioid doses may reduce chronic opioid therapy (COT) risks, but the feasibility of reducing opioid doses in community practice is unknown. Washington State and a health plan's group practice implemented initiatives to reduce high-dose COT prescribing. The group practice physicians were exposed to both initiatives, whereas contracted physicians were exposed only to statewide changes. Using interrupted time series analyses, we assessed whether these initiatives reduced opioid doses among COT patients in group practice (n = 16,653) and contracted care settings (n = 5,552). From 2006 to June 2014, the percentage of COT patients receiving ≥120 mg morphine equivalent dose declined from 16.8% to 6.3% in the group practice versus 20.6 to 13.6% among COT patients of contracted physicians. The proportion receiving excess opioid days supplied declined from 24.0 to 10.4% among group practice COT patients and from 20.1 to 14.7% among COT patients of contracted physicians. Reductions in prescribing of high opioid dose and excess opioid days supplied followed state and health plan initiatives to change opioid prescribing. Reductions were substantially greater in the group practice setting that implemented additional initiatives to alter shared physician expectations regarding appropriate COT prescribing, compared with the contracted physicians' patients. PerspectiveWashington State and a health plan's group practice implemented initiatives to reduce high-dose COT prescribing. Group practice physicians were exposed to both initiatives, whereas the health plan's contracted physicians were exposed to only the statewide changes. Reductions in prescribing of high opioid dose, average daily dose, and excess opioid days supplied followed state and health plan initiatives to change opioid prescribing. Reductions were substantially greater in the group practice setting that implemented additional initiatives to alter shared physician expectations regarding appropriate COT prescribing, compared with the contracted physicians' patients.

Practice settings and dentists’ job satisfaction

BackgroundThe nature and organization of dental practice is changing. The aim of this study was to explore how job satisfaction among dentists is associated with dental practice setting. MethodsA survey measured satisfaction with income, benefits, hours worked, clinical autonomy, work-life balance, emotional exhaustion, and overall satisfaction among dentists working in large group, small group, and solo practice settings; 2,171 dentists responded. The authors used logistic regression to measure differences in reported levels of satisfaction across practice settings. ResultsDentists working in small group settings reported the most satisfaction overall. Dentists working in large group settings reported more satisfaction with income and benefits than dentists in solo practice, as well as having the least stress. ConclusionsFindings suggest possible advantages and disadvantages of working in different types of practice settings. Practical ImplicationsDentists working in different practice settings reported differences in satisfaction. These results may help dentists decide which practice setting is best for them.

(196) The prevalence and characteristics of patients with indicators of opioid abuse within an integrated group practice

Epidemiological data indicates a significant increase in the use of opioids and problems of opioid abuse in the US during the past decade. The prevalence of opioid abuse within Group Practice settings has not been well characterized. In this study we examined the prevalence rates and characteristics of patients ≥18 years old with an encounter ICD-9 diagnosis for opioid abuse and/or clinician documented opioid abuse noted in the electronic health record among patients receiving chronic opioid therapy (COT) (defined as ≥70 days supply of a prescription opioid analgesic in at least one calendar quarter between 2006-2012) in the integrated group practice of Group Health Cooperative. Statistical significance was tested across groups using chi-square for categorical variables. We examined a random sample of 12,471 patients who received COT during this period (about half the patients receiving COT). Overall, 9.1% of patients had an ICD-9 diagnosis of opioid abuse. No significant difference in prevalence was observed according to gender, with 9.6% of males on COT having an ICD-9 code compared to 8.9% of females (p=0.24). A significant difference was observed across age groups with patients 18-44 years of age having the highest rates (13.1%), compared to 8.5% for 45-64 years of age, and 4.5% for those over 65 years of age (p<0.0001). These rates will be compared to those identified using natural language processing of the 4,644,224 clinical notes from patient encounters within the Group Health electronic medical record system to determine agreement between these two approaches and the utility of automated clinical note analysis in measuring rates of opioid abuse.This study was sponsored by Pfizer Inc. Epidemiological data indicates a significant increase in the use of opioids and problems of opioid abuse in the US during the past decade. The prevalence of opioid abuse within Group Practice settings has not been well characterized. In this study we examined the prevalence rates and characteristics of patients ≥18 years old with an encounter ICD-9 diagnosis for opioid abuse and/or clinician documented opioid abuse noted in the electronic health record among patients receiving chronic opioid therapy (COT) (defined as ≥70 days supply of a prescription opioid analgesic in at least one calendar quarter between 2006-2012) in the integrated group practice of Group Health Cooperative. Statistical significance was tested across groups using chi-square for categorical variables. We examined a random sample of 12,471 patients who received COT during this period (about half the patients receiving COT). Overall, 9.1% of patients had an ICD-9 diagnosis of opioid abuse. No significant difference in prevalence was observed according to gender, with 9.6% of males on COT having an ICD-9 code compared to 8.9% of females (p=0.24). A significant difference was observed across age groups with patients 18-44 years of age having the highest rates (13.1%), compared to 8.5% for 45-64 years of age, and 4.5% for those over 65 years of age (p<0.0001). These rates will be compared to those identified using natural language processing of the 4,644,224 clinical notes from patient encounters within the Group Health electronic medical record system to determine agreement between these two approaches and the utility of automated clinical note analysis in measuring rates of opioid abuse.This study was sponsored by Pfizer Inc.

The NUHS-frontier Family Medicine Clinic: a Singaporean experience on public-private partnership for healthcare

Objectives: Singapore’s healthcare landscape comprises public and private sector providers. Care in public sector institutions is heavily subsidised. The public polyclinics, comprising 14% of our primary care doctors, manage 45% of the country’s chronic disease load in primary care. This disproportionate distribution resulted in an under-utilisation of our private physician resource and strained the public sector. An innovative public-private partnership model was conceived to establish new Family Medicine Clinics (FMC). This may lead to better optimisation of healthcare resources, and lower overall healthcare costs. Methodology: The model involves a multi-disciplinary team led by private Family Physicians in a group practice setting. We will discuss the planning considerations to establish the country’s first FMC, the value propositions and how it aimed to address some of the gaps in the healthcare delivery system. Challenges and preliminary observations will be shared. Results: Extensive physician and patient engagement was conducted to promote this new model of care, resulting in increased referrals from the hospital’s specialist outpatient clinics. Continuity of care was established through shared medical records and close physician interaction between the hospital and FMC. Conclusions: Preliminary observations demonstrated a potential for this model to be replicated to strengthen healthcare delivery in Singapore and reduce fragmentation of care.

Assessment of Dabigatran Utilization and Prescribing Patterns for Atrial Fibrillation in a Physician Group Practice Setting

For years, warfarin and aspirin have been standard therapies for prophylaxis of stroke in atrial fibrillation. In late 2010, dabigatran, an oral direct thrombin inhibitor, became available for use in nonvalvular atrial fibrillation. We sought to evaluate utilization and prescribing patterns of dabigatran in a physician group practice setting. We retrospectively collected prescription data from October 2010 to December 2011 including indication of use, dose, renal function, drug interactions, history of warfarin therapy, and risk assessment scores (CHADS2 and HAS-BLED). Off-label use (history of valve disease or no diagnosis of atrial fibrillation) occurred in 20% (n = 34) of 174 patients. Renal function assessed by Cockcroft-Gault equation identified 1 case of contraindicated use and the need for initial renal dose adjustment in approximately 1/2 of the patients with reduced renal function (15-30 ml/min). Review of anticoagulant use revealed 68% of patients (n = 119) previously received warfarin and ultimately 20% of all patients on dabigatran resumed warfarin therapy. A significant increase in the use of permeability glycoprotein inhibitors and proton pump inhibitors after initiating dabigatran was observed. Nearly 10% of patients had a CHADS2 score of 0. For patients receiving novel oral anticoagulants, prospective inclusion in anticoagulation services and guidance from specific "place in therapy" statements have potential to play a large role in maximizing safety while aiding in continued research.

Mobile technologies and communication strategies in an urban Midwifery Group Practice setting. An exploratory study

Around-the-clock access to a known midwife is a distinct feature of Midwifery Group Practice (MGP) and caseload midwifery settings; although the literature suggests this aspect of working life may hinder recruitment and retention to this model of care. Mobile technologies, known as mHealth where they are used in health care, facilitate access and hence communication, however little is known about this area of midwifery practice. Which communication modalities are used, and most frequently, by MGP midwives and clients? A prospective, cross sectional design included a purposive sample of MGP midwives from an Australian tertiary maternity hospital. Data on modes of midwife-client contact were collected 24h/day, for two consecutive weeks, and included: visits, phone-calls, texts and emails. Demographic data were also collected. Details about 1442 midwife-client contacts were obtained. The majority of contact was via text, between the hours of 07:00 and 14:59, with primiparous women, when the primary midwife was on-call. An average of 96 contacts per fortnight occurred. The majority of contact was between the midwife and their primary clients, reiterating a key tenet of caseload models and confirming mobile technologies as a significant and evolving aspect of practice. The pattern of contact within social (or daytime) hours is reassuring for midwives considering caseload midwifery, who are concerned about the on-call burden. The use of text as the preferred communication modality raises issues regarding data security and retrieval, accountability, confidentiality and text management during off-duty periods. The development of Australian-wide guidelines to inform local policies and best practice is recommended.

Views of US Physicians About Controlling Health Care Costs

Physicians' views about health care costs are germane to pending policy reforms. To assess physicians' attitudes toward and perceived role in addressing health care costs. A cross-sectional survey mailed in 2012 to 3897 US physicians randomly selected from the AMA Masterfile. Enthusiasm for 17 cost-containment strategies and agreement with an 11-measure cost-consciousness scale. A total of 2556 physicians responded (response rate = 65%). Most believed that trial lawyers (60%), health insurance companies (59%), hospitals and health systems (56%), pharmaceutical and device manufacturers (56%), and patients (52%) have a "major responsibility" for reducing health care costs, whereas only 36% reported that practicing physicians have "major responsibility." Most were "very enthusiastic" for "promoting continuity of care" (75%), "expanding access to quality and safety data" (51%), and "limiting access to expensive treatments with little net benefit" (51%) as a means of reducing health care costs. Few expressed enthusiasm for "eliminating fee-for-service payment models" (7%). Most physicians reported being "aware of the costs of the tests/treatments [they] recommend" (76%), agreed they should adhere to clinical guidelines that discourage the use of marginally beneficial care (79%), and agreed that they "should be solely devoted to individual patients' best interests, even if that is expensive" (78%) and that "doctors need to take a more prominent role in limiting use of unnecessary tests" (89%). Most (85%) disagreed that they "should sometimes deny beneficial but costly services to certain patients because resources should go to other patients that need them more." In multivariable logistic regression models testing associations with enthusiasm for key cost-containment strategies, having a salary plus bonus or salary-only compensation type was independently associated with enthusiasm for "eliminating fee for service" (salary plus bonus: odds ratio [OR], 3.3, 99% CI, 1.8-6.1; salary only: OR, 4.3, 99% CI, 2.2-8.5). In multivariable linear regression models, group or government practice setting (β = 0.87, 95% CI, 0.29 to 1.45, P = .004; and β = 0.99, 95% CI, 0.20 to 1.79, P = .01, respectively) and having a salary plus bonus compensation type (β = 0.82; 95% CI, 0.32 to 1.33; P = .002) were positively associated with cost-consciousness. Finding the "uncertainty involved in patient care disconcerting" was negatively associated with cost-consciousness (β = -1.95; 95% CI, -2.71 to -1.18; P < .001). In this survey about health care cost containment, US physicians reported having some responsibility to address health care costs in their practice and expressed general agreement about several quality initiatives to reduce cost but reported less enthusiasm for cost containment involving changes in payment models.

Physician survey examining the impact of an educational tool for responsible opioid prescribing

In response to the need for physician education on proper opioid prescribing, the Federation of State Medical Boards (FSMB) and the FSMB Foundation, the philanthropic arm of the FSMB, commissioned and distributed Responsible Opioid Use: A Physician's Guide to more than 165, 000 licensed physicians in the United States. The book, written by pain management specialist Scott Fishman, MD, seeks tofurtherphysicians' continuing medical education by providing information on how to properly prescribe opioids to treat patients in pain. Although the book has been widely distributed, there have been no systematic studies of its impact. To address this knowledge gap, the authors surveyed licensed physicians in Georgia who received a copy of the book to determine whether it added to their knowledge about prescribing opioids, and if they planned to make changes in theirpractice based on reading the book. Six weeks after licensed physicians in Georgia received the book, a survey was sent to 12,666 of them via e-mail. A total of508 physicians completed the online survey. Of these, 82.1 percent rated the book either "very good" or "good" on providing pragmatic steps for improved care forpatients in pain, and more than 80 percent agreed that the book is a useful educational tool. Almost one-third (32.2percent) claimed that they intend to make changes to theirpractice after reading the book. The analysis also showed physicians in a solo practice were more likely to make changes (41.8percent) than their counterparts in office-based group practice (33.3 percent) and hospital-based (25.0 percent) settings. Primary care providers (41.6 percent) were also much more likely to make changes than physicians working in other specialty areas of medicine (22.8 percent). Well over half (57. 7percent) of the respondents indicated the book was better than other publications they had read on opioid prescribing and pain management. The results from this state-wide survey of licensed physicians demonstrate the value of educating physicians about how to appropriately prescribe, document, and treat patients who need opioid medications for pain management. The findings should be of value to organizations seeking to better educate physicians about appropriate opioid prescribing by providing insight into which physician population would be the most receptive to the type of information presented in Dr. Fishman's book. When faced with limited resources, an organizational strategy that first targets solo and primary care practitioners may improve physician educational efforts about prescribing opioids better than a strategy targeting medical and surgical specialists or those physicians participating in group practice settings.

Assessment of the appropriateness of serum digoxin concentration measurement in a medical group setting.

Recent quality initiatives require that the routine annual therapeutic drug-monitoring (TDM) parameters for the high-risk medication digoxin include a measure of renal function and a serum potassium level but not a serum digoxin concentration (SDC) measurement. Several studies have shown that the majority of the SDCs obtained in hospital settings provide little clinically actionable information. To evaluate the appropriateness and utility of SDCs ordered in a medical group practice setting by categorizing the reason the SDC was ordered and identifying action taken in response to the result. The descriptive study was conducted as a retrospective, electronic medical record (EMR) review of 90 primary care patients with continuous prescriptions for digoxin current on their medication profile with no gaps in therapy for at least 2 years prior to an SDC result entered into the EMR between January 1, 2009, and September 30, 2009. The reason the SDC was ordered was abstracted independently by 2 reviewers, who then assigned it to 1 of 8 predefined indication categories based on previously published criteria and practice guidelines. A third reviewer resolved inter-reviewer discrepancy (n = 1). A total of 90 patients with at least 1 SDC met inclusion criteria. Routine monitoring was the most frequent SDC order indication category with 35 patients (38.9%), 17 (48.6%) of whom did not have the recommended monitoring measures of potassium or renal function drawn concurrently. Patients were included in other categories as follows: confirmation of signs/symptoms of toxicity 30 (33.3%); assessment of factors altering pharmacokinetics 5 (5.6%); assessment of dosage change 5 (5.6%); assessment of drug interaction 3 (3.3%); assessment of clinical response 3 (3.3%); assessment of adherence 1 (1.1%); and other 2 (2.2%). Across all categories, a total of 19 (21.1%) of SDC results were outside the therapeutic range of 0.5 nanograms (ng) per mL and 2.0 ng per mL, 18 of which were below 0.5 ng per mL, with none of the subtherapeutic levels leading to a change in digoxin therapy. Only 1 patient (1.1%) had therapy changed in response to an elevated abnormal SDC result of 2.1 ng per mL and was in the routine monitoring category. The majority of SDC results obtained in our medical group setting did not lead to clinical action, such as dose adjustment or drug discontinuation. SDCs were commonly measured as part of routine monitoring, which is considered an inappropriate indication, and often without being accompanied by better markers for digoxin toxicity such as serum potassium levels and measures of renal function as recommended by drug-monitoring quality initiatives. Provider education is needed regarding the most indicative digoxin TDM parameters to obtain in order to satisfy quality initiatives.

PP9. Endovascular Management of Chronic Mesenteric Ischemia

Chronic Mesenteric Ischemia often presents in patients who are malnourished and nutritionally compromised, often exacerbated by a delay in diagnosis. These condition may predispose these patients to increased surgical risks in open surgery. We present our results of Endovascular management with percutaneous techniques in a large series of patients. A retrospective review of all patients diagnosed with chronic mesenteric ischemia was performed. All procedures were performed in a single group practice setting. Diagnoses was made by physical examination, patient history and ultrasound examination. Patients were treated between October 2003 through November 2008. Patients with acute mesenteric ischemia were excluded Follow up was performed both in office and with ultrasound. Analysis consisted of patient demographics, failure of treatment, need for re-intervention as well as morbidity and mortality. Between October 2003 and November 2008 133 mesenteric arteriograms were performed for patients in whom chronic mesenteric ischemia was suspected. Twenty one patients had normal arteriograms, 112 patients and 128 vessels were treated with either angioplasty alone or with stenting. Patient age ranged from 31 to 90 years old. Average age was 70. Seventy-five percent of the patients were women. No deaths occurred within the first 30 days. Six patients died within the first year, 2 from acute mesenteric ischemia, 3 from unrelated causes and 1 from unknown cause. Seventeen patients were lost to followup. Three patients after initial endovascular treatment were eventually converted to an open procedure. None of the patients required bowel resection. Patients with chronic mesenteric ischemia can be managed effectively with endovascular techniques. Many patients do require reintervention to maintain patencey, however this can be accomplished with minimal morbidity. Follow-up consisting of regular office visits and surveillance ultrasound is an important adjunct in the management of these complex patients.

Validation of self-reported history of hysterectomy and oophorectomy among women in an integrated group practice setting

Classification of menopause status often relies on self-report and is centrally important to research and clinical practice. This study was designed to assess the validity of self-reported hysterectomy and oophorectomy. A validation study of self-reported surgical menopause was conducted using survey data and electronic medical records from women enrolled in the Breast Cancer Screening Program within an integrated group practice in Washington State. Sensitivity of self-reported surgical history was estimated from questionnaire data among women with a history of hysterectomy (n = 1,935) and/or oophorectomy (n = 1,010) per medical records. Positive predictive values were quantified by reviewing medical records for a subset of women who self-reported a hysterectomy and/or oophorectomy (n = 122). Women self-reported hysterectomy history with great accuracy (sensitivity, 91%; positive predictive value, 97%) but were less accurate in reporting oophorectomy history (sensitivity of bilateral oophorectomy, 64%; positive predictive value, 100% and 73% for bilateral and unilateral oophorectomy, respectively). Among women self-reporting a unilateral oophorectomy, 19% had had both ovaries removed. Self-report is a valid data collection tool for hysterectomy history, but care should be taken in querying for and interpreting self-reported oophorectomy history for determining menopause status.

Managing a work–life balance: the experiences of midwives working in a group practice setting

Objective To explore how a group of midwives achieved a work–life balance working within a caseload model of care with flexible work hours and on-call work. Design in-depth interviews were conducted and the data were analysed using a data-driven thematic analysis technique. Setting Children, Youth and Women's Health Service (CYWHS) (previously Women's and Children's Hospital), Adelaide, where a midwifery service known as Midwifery Group Practice (MGP) offers a caseload model of care to women within a midwife-managed unit. Participants 17 midwives who were currently working, or had previously worked, in MGP. Findings analysis of the midwives’ individual experiences provided insight into how midwives managed the flexible hours and on-call work to achieve a sustainable work–life balance within a caseload model of care. Key conclusions it is important for midwives working in MGP to actively manage the flexibility of their role with time on call. Organisational, team and individual structure influenced how flexibility of hours was managed; however, a period of adjustment was required to achieve this balance. Implications the study findings offer a description of effective, sustainable strategies to manage flexible hours and on-call work that may assist other midwives working in a similar role or considering this type of work setting.

Medicare Part D Prescription Drug Benefits and Administrative Burden in the Care of Dually Eligible Psychiatric Patients

Medicare Part D Prescription Drug Benefits and Administrative Burden in the Care of Dually Eligible Psychiatric Patients

Community group practices in Canada: Are they ready to reform their practice?

Governments and healthcare organizations in Canada are reforming the clinical practice structures and policies to deliver primary care to the population. A key component of primary healthcare reform is the establishment of an interdisciplinary, community-based team approach to patient care. This study was undertaken to provide in-depth insight regarding primary healthcare providers' beliefs and attitudes in regard to their current group practice, what changes they believe are occurring and those necessary to reform group practice settings, their willingness to embrace changes, and the challenges they face to realize the proposed reform. This study employed a mixed-method research design (qualitative and quantitative data collection techniques) through day-long focus groups of primary healthcare professionals (eg, family physicians, specialists, dieticians, psychologists) from across Canada. There is considerable variation in the composition of primary care group practices across Canada. Respondents report that group practices are little more than an economic convenience to facilitate sharing of resources. Even when a practice is composed of several disciplines, there is little to no organized or systematic interaction among healthcare professionals aimed at improving patient care, lack of clarity as to identified leaders/managers of the team, and inconsistencies in the model of care provided to patients. However, there is a perception of value and benefit in working in a cohesive group practice to improve patient care. Findings revealed that although healthcare providers report themselves ready to make the necessary changes and willing to move to interdisciplinary team-based practices, there are substantive challenges that impede a movement to truly effective interdisciplinary team practice and functioning. These challenges include the type and allocation of funding, interprofessional healthcare provider education, changing the healthcare provision model, and barriers among healthcare professionals regarding shared and equitable team accountability for patient health outcomes.

The costs of chiropractic care in Minnesota

Summary Objective To determine the costs of delivering chiropractic services among Chiropractic Care of Minnesota, Inc.'s providers in Minnesota. Design Cross-sectional survey. Subjects Primary chiropractic providers in the Chiropractic Care of Minnesota, Inc. (CCMI) provider network. Methods A 14-item survey was used to collect 2004 chiropractic practice information. Sections included Practice structure and location (4 questions), Chiropractic treatment activity (4 questions), Employees (1 table), Annual expenses (1 table), Equipment (1 table) and Income (1 question). The survey was approved by CCMI. One hundred and fifty chiropractors’ names were randomly drawn from CCMI's provider roster. Surveys were distributed and returned anonymously by mail, with up to three mail contacts made to each chiropractor. Respondents were paid US$ 100 for a completed survey. Visit costs per patient were calculated by summing the total staff expenses plus the total annual clinic expenses, then dividing by the annual number of patients seen, using a 50-week working year. The average chiropractor's annual income from the Bureau of Labor Statistics was used to estimate the visit cost per patient that included a primary chiropractor's income. Results The final response rate was 80.5% (120/149). The majority of respondents work in solo practices (66.1%), urban areas (73%), and work full-time (61.7%). CCMI providers treat an average of 102 patients per week (median = 90). The average clinic costs are about US$ 205,000, with substantial variation. Costs tend to be higher in larger practices, especially those in multispecialty arrangements. The higher associated costs in group practice settings do not reflect a cost savings in the costs per patient. The moderate volume offices had the lowest costs per patient. Excluding any income for the primary chiropractor, the cost of a chiropractic patient visit is US$ 29.94 (mean, all clinics, 2004 dollars). To achieve an average chiropractor's income, the per visit cost would need to be US$ 60.09. Conclusions On average, CCMI providers have clinic costs of US$ 205,000 per year. We did not find economies of scale in group/multispecialty settings. The lowest costs per patient were seen in the moderate volume clinics.

Assessing Performance, Productivity, and Staffing Needs in Pathology Groups: Observations From the College of American Pathologists PathFocus Pathology Practice Activity and Staffing Program

The PathFocus program affords the opportunity for participating pathology practices to be compared with other practices that have similar characteristics. To demonstrate variability in workload among different pathology practice settings and to determine practice characteristics that influence staffing levels. Among 228 group practices in the PathFocus database, group practice settings were analyzed. The practice characteristics that were highly correlated with staffing levels are presented. Activities that showed significant variation include surgical pathology (P = .003), cytopathology (P = .006), miscellaneous (P = .006), and professional development (P = .003). Group practices report up to 4% of hours devoted to clinical pathology consultation, on average, and from 20% to 25% to administration and management. There are strong positive associations with staffing levels for lower-complexity Current Procedural Terminology code volumes (P < .001) and higher-complexity Current Procedural Terminology code volumes (P = .006). The settings of pathology practices carry specific commitments of time that are different and not equally distributed among all practice settings and strongly influence staffing requirements.