Non-primary Care Specialties Research Articles

The effect of education debt on PAs' specialty choice or preference.

This study investigated educational debt, repayment strategies, and other factors potentially related to recently certified physician associates/assistants' (PAs') choice or preference for primary care versus all other specialties. A national dataset from 2023 of recently certified PAs was used to conduct quantitative and qualitative analyses. Analyses were conducted separately for PAs who had accepted a clinical position and those who had not accepted a clinical position. Overall, 88% of respondents reported having educational debt, with 13.5% owing $200,000 or more. PAs from backgrounds underrepresented in medicine had accrued higher educational debt than their counterparts. Educational debt was significantly associated with specialty choices/preferences: PAs with higher debt were more likely to opt for nonprimary care specialties. Qualitative analyses revealed that PAs rely on different strategies for repaying their loans, depending on whether they choose or prefer primary care or nonprimary care specialties. These results suggest that educational debt plays a role in specialty selection, but other factors also are significant.

Trends of diversity in radiology trainees compared to other primary- and nonprimary-care specialties

Trends of diversity in radiology trainees compared to other primary- and nonprimary-care specialties

First-Year Resident Perceptions of Virtual Interviewing

Virtual interviews (VI) for residency programs present a relatively new paradigm for recruitment. To date, studies have been small, largely descriptive, and focused on surgical and subspecialty areas. The purpose of the study was to assess residents' perceptions about their VI experience and to compare those in primary care versus non-primary care specialties. An electronic survey was sent to 35 designated institutional officials in Illinois with a resulting snowball sample to assess first-year residents' perceptions of their virtual interviewing experience. A total of 82 postgraduate year-1 residents responded to the survey. We used descriptive analysis and χ2 tests to analyze results. Respondents were mostly female (52.4%), White (79%), non-Hispanic (76%), attending a university residency program (76.3%), and in a primary care specialty (61.7%). In general, most respondents (54.8%-75.3%) felt their VI accurately portrayed their residency program experience. Resident morale, resident-faculty camaraderie, and educational opportunities were perceived as being best portrayed in the VI. Compared to non-primary care residents, primary care residents felt that their program's VI more accurately portrayed the patient population served (P=.0184), resident morale in the program (P=.0038), and the overall residency experience (P=.0102). Still, 25.7% of respondents felt they were not accurately represented in the VI. Respondents reported that the VI portrays the residency experience fairly well, yet there is opportunity to improve the overall experience. The more difficult experiences to convey (morale, camaraderie, and the overall resident experience) may be areas in which primary care programs are outpacing other training programs.

Impact of Virtual Interviewing on Time and Financial Costs for NRMP© Applicants: Did Regional Campus Students Save More?

Background and Objectives: The sudden change from in-person to remote interviews by the National Residency Matching Program© (NRMP©) in 2020 was expected to result in significant financial and time savings for applicants. This project aimed to compare savings before and after the 2020-2021 interviewing season reported by students graduating from our institution’s regional and main campuses. Methods: Data were collected over a six-year period at a Midwestern medical school. Each year, approximately 120 main campus and 75 regional campus students are surveyed regarding specialty choice, number of applications and interviews, time, and expenses to complete the NRMP. Chi-square and t-tests were used to determine statistical differences by campus and by specialty in savings during the 2020-21 interviewing season compared to the previous five years. Results: Data were provided by 957 students. The response rates were 81.5% (regional) and 82% (main campus). Compared to the previous five years, in 2021 main campus students saved $3,990 (79.9%) and regional campus students saved $2,789 (77.1%). The previous highly significant differences in expenses between campuses ($1,386 ± $243) dropped to $185 (p = 0.3). On both campuses, applicants to non-primary care specialties saved more than their classmates applying to primary care. The largest average saving was reported by non-primary care applicants on the main campus ($4,207) and the smallest by regional applicants to primary care ($2,328). Main campus applicants reported saving 13.1 and regional campus 15.4 days interviewing in 2021. The smallest average time saving was reported by main campus applicants to non-primary care (12.7 days) and the largest (16.2 days) by regional campus applicants to primary care. No significant changes occurred in number of applications, interviews, or Match outcomes in 2021 compared to previous years. Conclusion: Prior to 2021, students from our institution’s regional campus reported lower costs and similar interviewing time than their peers on the main campus. Cost and time were significantly decreased in 2021 for both regional and main campus students applying to any specialty and differences between campuses reduced to non-significant levels. The number of applications, completed interviews, and Match outcomes remained similar to previous years. Changes to the NRMP© incorporating remote interviewing may reduce applicant costs by 80% and provide up to two weeks of available curricular time in the senior year of medical school.

Establishing osteopathic assessments to fulfill osteopathic recognition standards: a model for dermatology and other subspecialties.

The 5 year transition period for American Osteopathic Association (AOA) training programs to apply for and receive Accreditation Council for Graduate Medical Education (ACGME) accreditation (i.e.,the single graduate medical education system) was completed June 30, 2020. Of the previously AOA accredited programs that applied for or received osteopathic recognition (OR), only 24.5% are nonprimary care specialty programs according to the ACGME. The reluctance of specialty programs to apply for OR may be because osteopathic principles and practices (OPP) are not assessed. In order for programs to receive OR, they must have a standard method of assessment to assess osteopathic knowledge, including OPP and osteopathic manipulative treatment. In this Commentary, based on our assessment of the results of a literature review, we propose a model to provide a focused osteopathic assessment for the purposes of maintaining OR within residency training based on the ACGME six core competencies. Examples of multiple choice and essay questions are provided, as is a rubric for grading. The model is applied to the field of dermatology in this article and could serve as a blueprint to other subspecialties. With this framework, collaboration among programs will streamline the process to obtain OR in the ACGME single accreditation system.

Retention and change in PAs' first years of employment.

Employment analyses demonstrate that physician assistants (PAs) exhibit role flexibility in US medicine. The next step in understanding this labor-shifting observation is to know at what career stage it first occurs. Using matriculate data linked to the American Academy of PAs (AAPA) census survey data, a longitudinal analysis of seven graduate cohorts revealed that one-third of PAs changed specialty roles at least once during their first decade of employment. From this series, it appears that new PAs spend about 3.4 years in their first job, on average, before they decide to move to another medical or surgical field. In examining PAs who changed their clinical role during this time period, 28% shifted from primary care to another medical or specialty role. Overall, the PA career movement to nonprimary care specialties increased substantially. These findings support observations that PAs provide an adaptive role in a dynamic and changing medical workforce.

Attachment Characteristics and Speciality Choice among Medical Students

Based upon a study by Ciechanowski et al. [27], a parallel survey was performed at the medical school of the University of Jena with the goal to determine a relationship between specialty choice and attachment characteristics among medical students. A sample of 411 medical students from different phases of the medical training (73,2% females, mean age: 22.7 yrs.) were asked about their current specialty choice and invited to describe themselves in three different attachment questionnaires. These were the Relationship Style Questionnaire (RSQ), the Bielefeld Partnership Expectation Questionnaire and the Relationship-specific Attachment Scales for adults in the versions related to the mother and the partner. In comparing subgroups, we first used Ciechanowski et al.'s [27] differentiation of specialty contrasting primary and non-primary care specialties. In addition, a categorization of Buddeberg-Fischer et al. [29] differentiating a total of 7 subgroups was used (general medicine, internal medicine, surgery, anesthesiology/emergency medicine, pediatrics, psychiatry/neurology and obstetrics/gynecology). Comparing the groups according to Ciechanowski et al.'s categorization, differences occurred that were not replicating the original study: Students of the first subgroup (primary care) appeared to be more insecurely attached (according to the RSQ) and showed higher scores in subscales indicating dependency and preoccupation (e. g. fear of separation, dependently related to mother and partner). Similar as in Ciechanowski's study, the second group (non-primary care) revealed more individuals categorized as avoidant (or self-reliant). To differentiate the picture, the 7 categories according to Buddeberg-Fischer et al. [27] were compared. This comparison indicated that future pediatricians were classified as more insecure and ambivalent, whereas anesthesiologists more commonly were avoidant and dismissing. This picture was confirmed using comparisons of the questionnaire subscales. Since gender differences occurred both, related to specialty choice as well as attachment, gender was considered as a covariate in the analyses. In contrast to the study of Ciechanowski et al. [27], future pediatricians as part of the primary care group were characterized by a tendency to be dependent and preoccupied in all attachment measures, whereas the result of a tendency to be more avoidant and self-reliant among anesthesiologists and students choosing emergency medicine was more in line with the US-American study. Future research dealing with the motivation to choose specific fields of action in medicine should consider other psychological characteristics as well as biographical aspects.

Leveraging Interdisciplinary Teams for Pre-Visit Planning to Improve Pneumococcal Immunization Rates Among Internal Medicine Subspecialty Practices.

Background:Despite the ready availability of pneumococcal vaccines and recommendation of vaccination by Center for Disease Control and Prevention (CDC), the immunization rates among adults less than 65 years of age with chronic and immunocompromised conditions remain low.Methods:This interventional (cohort) study aimed to improve the pneumococcal vaccination rate for patients with an increased risk of pneumococcal disease by utilizing a three-pronged approach. This included: (1) clinician education webinar, (2) pre-visit counseling performed by registered nurses, targeted toward patients with upcoming appointments, to address vaccination status, and (3) modified pre-visit interdisciplinary team huddle with clinicians and registered nurses to review which patients are amenable to vaccination at the time of visit and those who may benefit from re-engagement and further motivational interviewing. After the completion of the 10-week intervention, study organizers reviewed the percent of patients with completed pneumococcal vaccinations.Results:In this 10-week rapid cycle initiative, a total of 482 patients were eligible for vaccination. During the intervention phase, 370 patients were contacted and of these 38% of patients were amenable to receiving a vaccine during the pre-visit counseling, 5% were previously vaccinated, 18% were not amenable, and 38% were unreachable prior to visit. This initiative resulted in a 43% increase in the vaccination rate in this cohort.Conclusions:The significant increase in vaccination rate supports the utilization of a framework in the multidisciplinary approach to pre-visit planning in non-primary care specialties and other vaccination efforts, especially emerging diseases such as COVID-19. Future directions of study include the efficacy of telemedicine counseling with a same-day appointment for vaccination, co-location of registered nurses within the practice sites, as well as the use of other ancillary staff (such as medical office assistants) to engage patients in pre-visit planning.

Neurology eConsults at Penn State Health: What, Why, and How?

eConsults provide a mechanism for specialists to provide guidance to their colleagues to allow them to manage patients in primary care settings. The patient receives access to specialist expertise, avoids the long wait time and high costs associated with an office visit, and maintains relationship continuity with the primary care physician (PCP). The PCP has dynamic access to specialist expertise and an opportunity for attainting a higher comfort level with chronic neurological care comanagement. Patient referrals for specialty care are high, while there has been projected shortage in nonprimary care specialties. The increasing prevalence of neurologic diseases associated with an aging population will likely continue to increase the demand for neurologists.

Association between medical student debt and choice of specialty: a 6-year retrospective study

BackgroundThe effect of rapidly increasing student debt on medical students’ ultimate career plans is of particular interest to residency programs desiring to enhance recruitment, including primary care specialties. Previous survey studies of medical students indicate that amount of student debt influences choice of medical specialty. Research on this topic to date remains unclear, and few studies have included the average income of different specialties in analyses. The purpose of this study is to observe whether empirical data demonstrates an association between debt of graduating medical students and specialties into which students match.MethodsThis was a retrospective cross-sectional study of a public institution including data from graduation years 2010–2015. For each included student, total educational debt at graduation and matched specialty were obtained. Average income of each specialty was also obtained. Statistical hypothesis testing was performed to analyze any differences in average debt among specialties; subanalysis was performed assessing debt for primary care (PC) versus non-primary care (NPC) specialties. Correlation between student debt and average specialty income was also evaluated.ResultsOne thousand three hundred ten students met the inclusion criteria and 178 were excluded for a final study population of 1132 (86%). The average debt was $182,590. Average debt was not significantly different among the different specialties (P = 0.576). There was no significant difference in average debt between PC and NPC specialties (PC $182,345 ± $64,457, NPC $182,868 ± $70,420, P = 0.342). There was no correlation between average specialty income and graduation debt (Spearman’s rho = 0.021, P = 0.482).ConclusionsAt our institution, student indebtedness did not appear to affect matched medical specialty, and no correlation between debt and average specialty income was observed. Different subspecialties and residency programs interested in recruiting more students or increasing diversity may consider addressing alternative factors which may have a stronger influence on student choices.

Role of Debt and Loan Forgiveness/Repayment Programs in Osteopathic Medical Graduates' Plans to Enter Primary Care.

Osteopathic medicine emphasizes partnering with patients to help them attain or maintain health. This philosophy encourages physicians to practice primary care and a mission of improving community health. However, there is currently a shortage of primary care physicians in many areas of the United States. To determine whether intended practice patterns of recent graduates of colleges of osteopathic medicine favor primary care and whether practice patterns correlate with medical education debt. Responses were analyzed from the American Association of Colleges of Osteopathic Medicine survey of pending medical school graduates from 2007 through 2016 regarding indebtedness and specialty selection. The percentage of graduating osteopathic medical students who chose a primary care specialty increased from 28.1% (676 students) in 2007 to 33.2% (1377 students) in 2016. Among graduates, those above the 75th percentile of debt had a general move toward more non-primary care positions, with a value of 74.4% in 2007 and 79.9% in 2016. Graduates below the 25th percentile had a gradual increase in primary care representation, moving from 24.6% in 2007 to 29.4% in 2016. In 2007, graduates with a loan forgiveness/repayment program were more likely to choose primary care over graduates without such a program (OR, 0.681 [95% CI, 0.505-0.920]; P=.02). Analysis of subsequent years showed a declining OR with increasing significance. Results of this analysis indicated that increased educational debt loan directly influenced physician practice choice. Graduates with high debt burden were more likely to enter primary care fields and use loan forgiveness/repayment programs. Graduates with high debt burden who did not use loan forgiveness/repayment programs were more likely to enter non-primary care specialty fields, with this trend increasing as mean medical school debt increased. This association has implications for policies that could affect choice of primary care. However, further research is needed to fully understand the primary care choice by graduates of colleges of osteopathic medicine.

Pre-medical majors in the humanities and social sciences: impact on communication skills and specialty choice.

Medical school admissions committees use a variety of criteria to determine which candidates to admit to their programmes. Effective communication is increasingly considered a key requisite to the practice of effective medicine. Medical students with pre-medical backgrounds in the humanities and social sciences may be more likely to acquire skills relevant to patient-centred communication, either prior to or during medical school. The purpose of this study was to investigate the relationship between pre-medical backgrounds in the humanities and social sciences and outcomes in medical school, including in communication and interpersonal skills (CIS), licensure examination results and postgraduate specialty choice (primary care versus non-primary care specialties). The American Medical College Application Service database was used to identify pre-medical college majors, demographic characteristics, Medical College Admission Test scores and college grade point averages for medical students at a large, midwestern medical school. Data were obtained for 465 medical students across three cohorts (classes of 2014-2016). Correlation and regression analyses were used to examine relationships between pre-medical background, performance on graduation competency examination standardised patient encounter CIS scores and on United States Medical Licensing Examination (USMLE) Step1 and Step2 Clinical Knowledge scores, and postgraduate specialty choice. Graduating medical students with pre-medical humanities or social sciences majors performed significantly better in terms of CIS than those with natural science majors (Cohen's d=0.28, p=0.011). There were no significant associations between pre-medical majors and USMLE Step1 and Step2 Clinical Knowledge scores or postgraduate specialty choice. These results suggest that considering humanistic factors as part of admissions criteria may promote the selection and training of physicians with good communication skills.

Physician Perception of Pay Fairness and its Association with Work Satisfaction, Intent to Leave Practice, and Personal Health.

Primary care physicians generally earn less than specialists. Studies of other occupations have identified perception of pay fairness as a predictor of work- and life-related outcomes. We evaluated whether physicians' pay fairness perceptions were associated with their work satisfaction, turnover intention, and personal health. Three thousand five hundred eighty-nine physicians were surveyed. Agreement with "my total compensation is fair" was used to assess pay fairness perceptions. Total compensation was self-reported, and we used validated measures of work satisfaction, likelihood of leaving current practice, and health status. Hierarchical logistic regressions were used to assess the associations between pay fairness perceptions and work/life-related outcomes. A total of 2263 physicians completed surveys. Fifty-seven percent believed their compensation was fair; there was no difference between physicians in internal medicine and non-primary care specialties (P= 0.58). Eighty-three percent were satisfied at work, 70% reported low likelihood of leaving their practice, and 77% rated their health as very good or excellent. Higher compensation levels were associated with greater work satisfaction and lower turnover intention, but most associations became statistically non-significant after adjusting for pay fairness perceptions. Perceived pay fairness was associated with greater work satisfaction (OR, 4.90; 95% CI, 3.94-6.08; P< 0.001), lower turnover intention (OR, 2.46; 95% CI, 2.01-3.01; P< 0.001), and better health (OR, 1.33; 95% CI, 1.08-1.65; P< 0.01). Physicians who thought their pay was fair reported greater work satisfaction, lower likelihood of leaving their practice, and better overall health. Addressing pay fairness perceptions may be important for sustaining a satisfied and healthy physician workforce, which is necessary to deliver high-quality care.

Patient Outcomes and Cost of Referral Patterns of Patients With Proton Pump Inhibitor Refractory Gastroesophageal Reflux Disease Undergoing Esophageal pH and Impedance Testing

Introduction: The American College of Gastroenterology recommends that patients with gastroesophageal reflux disease (GERD) undergo esophageal pH and impedance for symptoms persisting following an 8 week trial of proton pump inhibitor (PPI) therapy. Research suggests that early referral is cost effective in evaluating PPI refractory GERD. Methods: A retrospective chart review was performed on all patients that underwent esophageal pH/impedance studies from December 2010 to June 2015. DeMeester score, total acid and non-acid reflux events, reflux symptom index scores, demographics, prior specialty appointments, and testing related to GERD symptoms was recorded. Workup cost was estimated using the minimum Medicare facility payment. Results: A total of 119 patients underwent pH/impedance testing with a mean age of 48 years (SD 13.0, range 21 - 76). No patients had pH/impedance evaluations prior to 8 weeks of PPI therapy. 46 (39%) patients had positive DeMeester scores, and 64 (53.8%) were referred by a non-primary care provider. Non-primary care specialties and primary care managers (PCM) had 26/64 (41%) and 20/55 (36%) positive pH/impedance tests, respectively. Of 55 patients referred by a PCM, 19 were previously seen by another specialty, with 6/19 (32%) of those having positive pH/impedance studies. No significant difference was found in the prevalence of positive testing between the three referral pattern groups (χ2=0.5068; P=0.7762) (table 1). Evaluation and workup costs averaged (95% CI) $184.00($181.46 - $186.54) from primary care referrals, $420.58 ($302.14 - 539.02) for primary care with previous subspecialty evaluation, and $353.65 ($264.12 - 443.18) for subspecialty referrals independent of PPI usage. Costs differed between primary care referrals and primary care with subspecialty referrals (P=0.0005) and primary care and subspecialty referrals (P=0.0014) but not between primary care with subspecialty referrals and subspecialty referrals (P=0.3649). Conclusion: A majority of the patients referred for pH/impedance testing were previously evaluated by another medical or surgical subspecialty. There was no difference in positive study between referral patterns. Additionally, the cost of workup for the PPI refractory GERD was higher in patients with any previous subspecialty workups when compared to direct primary care referrals. Therefore, the additional cost of workup of symptoms related to GERD does not demonstrate increased prevalence of positive pH and impedance studies. Early referral from primary care to gastroenterology for patients with refractory GERD after a trial of PPIs could reduce costs by eliminating unnecessary referrals to other specialties.Table: Table. Number of positive and negative DeMeester scores based on referral pattern for pH and impedance testing

Factors associated with less-than-full-time working in medical practice: results of surveys of five cohorts of UK doctors, 10years after graduation.

BackgroundThe greater participation of women in medicine in recent years, and recent trends showing that doctors of both sexes work fewer hours than in the past, present challenges for medical workforce planning. In this study, we provide a detailed analysis of the characteristics of doctors who choose to work less-than-full-time (LTFT). We aimed to determine the influence of these characteristics on the probability of working LTFT.MethodsWe used data on working patterns obtained from long-term surveys of 10,866 UK-trained doctors. We analysed working patterns at 10 years post-graduation for doctors of five graduating cohorts, 1993, 1996, 1999, 2000 and 2002 (i.e. in the years 2003, 2006, 2009, 2010 and 2012, respectively). We used multivariable binary logistic regression models to examine the influence of a number of personal and professional characteristics on the likelihood of working LTFT in male and female doctors.ResultsAcross all cohorts, 42 % of women and 7 % of men worked LTFT. For female doctors, having children significantly increased the likelihood of working LTFT, with greater effects observed for greater numbers of children and for female doctors in non-primary care specialties (non-GPs). While >40 % of female GPs with children worked LTFT, only 10 % of female surgeons with children did so. Conversely, the presence of children had no effect on male working patterns. Living with a partner increased the odds of LTFT working in women doctors, but decreased the odds of LTFT working in men (independently of children). Women without children were no more likely to work LTFT than were men (with or without children). For both women and men, the highest rates of LTFT working were observed among GPs (~10 and 6 times greater than non-GPs, respectively), and among those not in training or senior positions.ConclusionsFamily circumstances (children and partner status) affect the working patterns of women and men differently, but both sexes respond similarly to the constraints of their clinical specialty and seniority. Thus, although women doctors comprise the bulk of LTFT workers, gender is just one of several determinants of doctors’ working patterns, and wanting to work LTFT is evidently not solely an issue for working mothers.Electronic supplementary materialThe online version of this article (doi:10.1186/s12960-016-0162-3) contains supplementary material, which is available to authorized users.

Physician Empathy Towards Patients: A Survey in Iranian Teaching Hospitals

Background and Objectives: Empathy is a key element of physician-patient relations, playing a significant role in effectiveness of health care. This study aimed to evaluate the level of empathy of specialist physicians and advise strategies to promote empathy. Methods: All 142 specialist physicians practicing in teaching hospitals of Zanjan City (Northern Iran) were surveyed. The 20-item Jefferson Scale of Physician Empathy (JSPE) was used as the study tool. The answers were quantified on a 7-point Likert-type scale ranging from strongly disagree (1) to strongly agree (7). Data were summarized using descriptive statistical methods. The mean values were compared by t-test and ANOVA. Findings: The overall empathy score averaged at 100.7 ± 17.7 falling within the moderate range (max = 140). While the highest score of the empathy dimensions was received by compassionate care (5.22) and the lowest score was belonged to standing in the patient’s shoes (4.89). Female physicians exhibited significantly higher empathy level (107.3 ± 15.6) compared to their male counterparts (96.4 ± 16.6) (P = 0.003). The empathy score mean was found to be significantly higher among physicians with human-mediatedspecialties (113.05 ± 16.2) as compared with technology mediated, tool-mediated, and non-primary care specialties which scored 98 ± 12.12, 98.2 ± 18.7, and 97.1 ± 15.9, respectively (F = 5.14, P = 0.002). Conclusions: The observed level of empathy among physicians indicates a large room for improvement, particularly among male doctors and technology/tool mediated specialties. Considering the crucial role of clinical empathy in patient satisfaction and outcome, our results recommend further studies to examine the issue on larger scales and devise intervention strategies if the observed gap will be confirmed.

Osteopathic Students' Graduate Medical Education Aspirations Versus Realities: The Relationship of Osteopathic Medicine and Primary Care.

Osteopathic medicine is closely identified with primary care. The mission statements of a majority of colleges of osteopathic medicine (COMs) mention the goal of producing primary care physicians. By far, there are more family medicine and internal medicine residency programs in the American Osteopathic Association graduate medical education (GME) system than programs for any other specialty. In addition, the osteopathic profession is embarking on a new direction to ensure COM graduates are trained as practice-ready primary care physicians. In counterpoint to the osteopathic profession's emphasis on primary care, the majority of entering and graduating osteopathic medical students express preferences for residencies in non-primary care specialties. When graduating students confront their GME options, however, they discover their choices for non-primary care specialties are limited. Currently, approximately two-thirds of COM graduates end up in a primary care residency. The creation of a unified GME accreditation system under the Accreditation Council for Graduate Medical Education (ACGME) may further consolidate the osteopathic identity with primary care: Osteopathic training institutions may reduce the number of non-primary care programs they offer, which would allow them to increase enrollment in primary care programs to meet ACGME standards and remain below their Medicare caps. Additionally, in the National Resident Matching Program Match, selection patterns by program directors for competitive non-primary care residencies currently favor U.S. MDs. Therefore, while osteopathic students enter COMs aspiring to careers in non-primary care specialties, they are encountering a GME environment that offers them a shrinking number of alternatives.

Screening for High Blood Pressure in Adults During Ambulatory Nonprimary Care Visits: Opportunities to Improve Hypertension Recognition.

Visits with nonprimary care providers such as optometrists may be missed opportunities for the detection of high blood pressure (BP). For this study, normotensive adults with at least 12 months of health plan membership on January 1, 2009 (n=1,075,522) were followed-up for high BP through March 14, 2011. Of 111,996 patients with a BP measurement ≥140/90 mm Hg, 82.7% were measured during primary care visits and 17.3% during nonprimary care visits. Individuals with a BP ≥140/90 mm Hg measured during nonprimary care visits were older and more likely to be male and non-Hispanic white. The proportion of patients with follow-up and false-positives were comparable between primary and nonprimary care. The main nonprimary care specialty to identify a first BP ≥140/90 mm Hg was ophthalmology/optometry with 24.5% of all patients. Results suggest that expanding screening for hypertension to nonprimary care settings may improve the detection of hypertension.

Cardiology and accountable care.

Cardiovascular disease is the leading cause of death in the United States and accounts for ≈17% of national health expenditures and 30% of Medicare spending.1 Among physician groups and professional societies, cardiologists have been among those leading efforts to create evidence-based guidelines and to measure quality of care. In the post-health reform era, national efforts have expanded beyond quality to include innovative delivery models, such as the patient-centered medical home (PCMH), the medical neighborhood, and accountable care organizations (ACOs). This next generation of care models and the payment strategies that support them incentivize efficiency, patient-centeredness, and care coordination with an emphasis on primary care. We propose strategies for cardiologists to create collaborative opportunities within these new models drawing from examples from around the country within the context of a framework developed by the American College of Physicians.2 Pursuing these approaches or others along similar lines will enable cardiologists to lead and to be active participants in shaping delivery system transformation. These innovative delivery models share similar features. The PCMH is a model of care that emphasizes additional support for primary care providers within a patient-centered team, whereas a medical neighborhood represents a broader collection of primary care doctors, specialists such as cardiologists, hospitals, and other stakeholders within a region that seek to reduce fragmented care by sharing accountability.2,3 The ACO, too, is a broader care delivery arrangement, but in this case, groups of providers are accountable for the quality, cost, and overall care of a particular population, typically defined by the payer. In the Medicare Shared Savings Program (MSSP), an ACO model for Medicare beneficiaries, the ACO can capture shared savings if it reduces its healthcare expenditures and meets certain quality performance standards, nearly half of which are related to cardiovascular disease.4 Within the …

Despite substantial progress In EHR adoption, health information exchange and patient engagement remain low in office settings.

The United States is making substantial investments to accelerate the adoption and use of interoperable electronic health record (EHR) systems. Using data from the 2009-13 Electronic Health Records Survey, we found that EHR adoption continues to grow: In 2013, 78percent of office-based physicians had adopted some type of EHR, and 48percent had the capabilities required for a basic EHR system. However, we also found persistent gaps in EHR adoption, with physicians in solo practices and non-primary care specialties lagging behind others. Physicians' electronic health information exchange with other providers was limited, with only 14percent sharing data with providers outside their organization. Finally, we found that 30percent of physicians routinely used capabilities for secure messaging with patients, and 24percent routinely provided patients with the ability to view online, download, or transmit their health record. These findings suggest that although EHR adoption continues to grow, policies to support health information exchange and patient engagement will require ongoing attention.