Primary Care Internal Medicine Clinic Research Articles

Separate But Not Equal? A Cross-Sectional Study of Segregation by Payor Mix in Academic Primary Care Clinics.

At some US Academic Health Centers (AHCs), patients with predominantly Medicaid insurance are seen in one clinic and patients with other insurance are seen in another. The extent of this practice and implications are unknown. To estimate the proportion of AHCs that have at least two primary care internal medicine clinics that differ substantially in proportion of patients with Medicaid and to compare patient demographic, staffing, and operational features. General internal medicine chiefs and clinic directors at 40 randomly selected US AHCs plus the top 10 AHCs in terms of NIH funding. An AHC was classified as maintaining clinics that differed substantially in the proportion of patients with Medicaid if any two differed by ≥ 40% (absolute). Other criteria were used for pre-specified secondary analyses (e.g., ≥ 30%). Thirty-nine of 50 AHCs (78%) participated. Four of 39 (10%; 95% CI, 3 to 24%) had two clinics differing by ≥ 40% in the proportion of patients with Medicaid, eight (21%; 95% CI, 9 to 36%) had clinics differing by ≥ 30%, and 15 (38%; 95% CI, 23 to 55%) had clinics differing by ≥ 20%. Clinics with more patients with Medicaid by any of the three criteria were more likely to employ resident physicians as providers of longitudinal care (with faculty supervision) and more likely to have patients who were Black or Hispanic. Some US AHCs maintain separate clinics defined by the proportion of patients with Medicaid. Clinics with a higher proportion of patients insured by Medicaid are more likely to employ residents (with faculty oversight), feature residents as providers of longitudinal care, and serve patients who are Black and Hispanic. Further research is needed to understand why some AHCs have primary care clinics distinguishable by insurance mix with the goal of ensuring that racism and discrimination are not root causes.

Patient Perceptions of Osteoporosis Treatment Thresholds

Many older patients express concerns about medication risks, and have higher risk thresholds than physicians for cardiovascular preventive medications. We hypothesized that patients have relatively high risk thresholds for fracture preventive medications. Women ≥ 60 years old were recruited from 3 primary care internal medicine clinics in Wisconsin. Participants were provided information regarding fracture risks and treatment risks and benefits, followed by a series of vignettes depicting a 70-year-old woman at baseline fracture risks between 5-50%. Fracture risks were shown graphically and treatment side effects were provided for each vignette, and participants were asked to respond regarding whether they would accept treatment. The association of vignette treatment acceptance with participant beliefs regarding medication risks was examined in analyses adjusted for perceived risk of medications, patient numeracy, and prior respondent experience with osteoporosis. The mean age of women in the cohort was 69.4 years (SD 7.29). Ninety-one percent were non-Hispanic whites, 34% reported a history of fracture, and 20.3% a history of osteoporosis. Subjects varied substantially in their responses to vignettes, but only 51% reported they would accept prescription osteoporosis treatment at the threshold currently recommended by national physician treatment guidelines, and fewer would accept treatment at lower risks. Belief that medications are generally not worth their risks was associated with lower acceptance of treatment at all levels of fracture risk. There is substantial variability in preferences for postmenopausal osteoporosis treatment. Presentation of individualized fracture risks as recommended by current guidelines has potential to allow better targeting to higher-risk patients, but further work is needed regarding how to present this information and counsel patients.

44-Year-Old Man With Shortness of Breath, Fatigue, and Paresthesia

44-year-old man presented to the Primary Care Internal Medicine clinic with a 1-month history of shortness of breath, fatigue, and paresthesia. He reported increasing shortness of breath while stocking shelves at work and recently stopped recreational jogging because of this symptom. He also described a new, painless numbness and tingling in his fingertips bilaterally. The patient denied any history of chest pain, syn- cope, palpitations, muscle weakness, incontinence, weight changes, or recent illness. He was taking no prescription or over-the-counter medications or food supplements. He had no other relevant medical or surgical history. He had never used tobacco or illicit drugs and consumed an average of 1 alcoholic beverage per month. He had no siblings. Family history was remarkable for coronary artery disease in his father and osteoarthritis in his mother. Physical examination revealed a blood pressure of 101/58 mm Hg, with a regular pulse of 86 beats/min. The patient was afebrile, alert, and well nourished. Head and neck evaluation demonstrated a supple neck without ten- derness to palpation or carotid bruits. Scleras were normal. Neck range of motion and strength were normal. Findings on thyroid and lymph node examinations were unremark- able. Cardiac examination revealed normal first and second heart sounds without murmurs, gallops, or rubs. Lung sounds were clear. The patient's skin was pale. Abdominal examination revealed no tenderness, masses, or hepatosple- nomegaly. Cranial nerve examination revealed no abnor - malities in cranial nerves II through XII. Sensation was intact throughout, except for reduced pinpoint discrimina- tion of the bilateral finger tips. The Phalen maneuver and Tinel sign were negative. The extremities, including the th- enar musculature, were of normal tone, bulk, and strength, with symmetric and normal reflexes throughout. The lower extremities had mild varicosities but were not edematous. Babinski testing was normal. Gait testing was normal ex- cept for mild unsteadiness during the tandem walk.

Measuring the Intensity of Resident Supervision in the Department of Veterans Affairs: The Resident Supervision Index

To develop a survey instrument designed to quantify supervision by attending physicians in nonprocedural care and to assess the instrument's feasibility and reliability. In 2008, the Department of Veterans Affairs (VA) Office of Academic Affiliations convened an expert panel to adopt a working definition of attending supervision in nonprocedural patient care and to construct a survey to quantify it. Feasibility was field-tested on residents and their supervising attending physicians at primary care internal medicine clinics at the VA Loma Linda Healthcare System in their encounters with randomly selected outpatients diagnosed with either major depressive disorder or diabetes. The authors assessed both interrater concurrent reliability and test-retest reliability. The expert panel adopted the VA's definition of resident supervision and developed the Resident Supervision Index (RSI) to measure supervision in terms of residents' case understanding, attending physicians' contributions to patient care through feedback to the resident, and attending physicians' time (minutes). The RSI was field-tested on 60 residents and 37 attending physicians for 148 supervision episodes from 143 patient encounters. Consent rates were 94% for residents and 97% for attending physicians; test-retest reliability intraclass correlations (ICCs) were 0.93 and 0.88, respectively. Concurrent reliability between residents' and attending physicians' reported time was an ICC of 0.69. The RSI is a feasible and reliable measure of resident supervision that is intended for research studies in graduate medical education focusing on education outcomes, as well as studies assessing quality of care, patient health outcomes, care costs, and clinical workload.

Increased Frequency of No-Shows in Residents’ Primary Care Clinic Is Associated With More Visits to the Emergency Department

The high prevalence of no-shows in residents' primary care clinic acts as a barrier to continuity of care, results in loss of outpatient learning opportunities, and may result in more emergency department (ED) visits. The authors seek to identify if high rates of no-shows correlate with more ED visits. In a selected primary care internal medicine (PCIM) continuity clinic, 650 patients were randomly selected, with 325 patients each from the faculty and resident practices. The number of ED visits between January 1, 2006, and December 30, 2008, was recorded. Demographic characteristics of the population were obtained, and comparisons between the faculty and resident groups were performed using Student t test. Linear multiple regression analysis was performed to compare frequency of ED visits between the faculty and the resident groups, controlling for age, interpreter requirement, number of ED visits, proportion of no-shows, and insurance type. A P value <.05 was considered statistically significant. During 2006-2008, the average number of ED visits per patient in the faculty's practice was 2.1 compared with 4.1 in the resident's practice (P < .001). A multiple linear regression model showed that patients who had more ED visits were likely to be younger (P = .004), had shorter duration of care in the PCIM clinic (P < .001), and had a higher proportion of no-shows to the PCIM clinic (P < .001). There was no statistical difference between faculty and resident practice after adjusting for the above-mentioned variables. Shorter duration in the PCIM clinic and higher proportion of missed appointments were associated with more ED visits, but the use of interpreters and Medicaid insurance did not result in more ED visits. Future interventions are necessary to reduce the no-show rate in the clinic as this may result in a reduction of ED visits.

Medication reconciliation in ambulatory care: attempts at improvement

Objective:To enhance overall accuracy of medication lists by providing performance feedback and training to the healthcare team and increasing patient participation in the medication reconciliation process.Methods:This prospective study involved patients...

Does Health Service Use in a Diabetes Management Program Contribute to Health Disparities at a Facility Level? Optimizing Resources with Demographic Predictors

The objective of this study was to determine if demographic variation in the use of health service resources among type 2 diabetes patients contributes to health disparities. A prospective cohort design was used to analyze differences in health care utilization among 315 adults registered in primary care internal medicine clinics of an academic medical center. Patients were cared for by interdisciplinary teams of internal medicine residents, nurse practitioner students, and pharmacy students supervised by interdisciplinary faculty. A post hoc multivariate repeated measures analysis, using generalized estimating equation (GEE) statistical modeling, was used to determine if age, sex, race, ethnicity, marital status, primary language, and insurance predicted use of health care services (ie, primary care, acute care, emergency department [ED], hospitalization). Medicare/Medicaid-insured patients had an average of 2.49 primary care visits per month (P < .0001) and 75% more ED visits (P < .001) during the study than patients with other insurance types. ED visits for Hispanics grew by a factor of 3.3 compared to non-Hispanics (P < .0001). Females had 52% more hospitalizations than males (P < .05), and Hispanics had 44% fewer hospitalizations than non-Hispanics (P < .05). Analysis of selected health status indicators showed no significant differences for HbA1c, significantly greater likelihood of blood pressure >130/80 with every 5-year increase in age, and significantly greater likelihood of low-density lipoprotein >100 among Medicare/Medicaid-insured patients. Sociodemographic characteristics are predictive of health care services use and suggest that, although equally available to all participants, the use of health care resources vary at the facility level and are independent of diabetes health status outcomes.

Prevalence of and risk factors for colonization with methicillin-resistant Staphylococcus aureus in an outpatient clinic population.

To determine the prevalence of methicillin-resistant Staphylococcus aureus (MRSA) colonization in an outpatient population and to identify risk factors for MRSA colonization. Surveillance cultures were performed during outpatient visits to identify S. aureus colonization. A case-control study was performed to identify risk factors for MRSA colonization. Primary care internal medicine clinic. Adults presenting for non-acute primary care (N = 494). S. aureus was isolated from 122 (24.7%) of the patients for whom cultures were performed. Methicillin-susceptible S. aureus was isolated from 107 (21.7%) of the patients, whereas MRSA was isolated from 15 (3.0%) of the patients. All MRSA isolates were resistant to multiple non-beta-lactam antimicrobial agents. In multivariate analyses, MRSA colonization was independently associated with admission to a nursing home (adjusted odds ratio [OR], 103; 95% confidence interval [CI95], 7 to 999) or hospital in the previous year, although the association with hospital admission was observed only among those without chronic illness (adjusted OR, 7.1; CI95, 1.3 to 38.1). In addition, MRSA colonization was associated with the presence of at least one underlying chronic illness, although this association was observed only among those who had not been hospitalized in the previous year (adjusted OR, 5.1; CI95, 1.2 to 21.9). We found a low prevalence of MRSA colonization in an adult outpatient population. MRSA carriers most likely acquired the organism through contact with healthcare facilities rather than in the community. These data show that care must be taken when attributing MRSA colonization to the community if detected in outpatients or during the first 24 to 48 hours of hospitalization.

The discussion about advance directives. Patient and physician opinions regarding when and how it should be conducted. End of Life Study Group.

Widely publicized court cases have focused national attention on the importance of advance directives. In spite of initiatives such as the Patient Self-Determination Act of 1991, fewer than 10% of Americans have prepared advance directives. One way to increase the preparation of advance directives may be to increase the frequency and quality of discussions about them between individual patients and their physicians. We performed a multicenter observational study to assess the opinions of primary care patients and physicians regarding these discussions. This was a cross-sectional descriptive survey of randomly selected primary care patients and physicians in eight primary care internal medicine clinics in the eastern and midwestern United States. Quantitative questionnaires were used to elicit subjects' demographic characteristics, and their opinions regarding the timing, content, and location of discussions about advance directives. The 883 subjects included 329 adult outpatients, 282 resident physicians, and 272 practicing physicians. Physician and patient response rates were 75% and 76%, respectively. Patients felt that the discussion should occur earlier than did the physicians: at an earlier age, earlier in the natural history of disease, and earlier in the patient-physician relationship. Most subjects agreed it was the physician's responsibility to initiate the discussion. We defined a discrepancy between the preferences of primary care patients and physicians regarding the timing of the discussion about advance directives. We propose physician education regarding patient preferences as the most effective way to accomplish the goal of improving the frequency and quality of discussions about advance directives.

The Discussion About Advance Directives

Background: Widely publicized court cases have focused national attention on the importance of advance directives. In spite of initiatives such as the Patient Self-Determination Act of 1991, fewer than 10% of Americans have prepared advance directives. One way to increase the preparation of advance directives may be to increase the frequency and quality of discussions about them between individual patients and their physicians. We performed a multicenter observational study to assess the opinions of primary care patients and physicians regarding these discussions. Methods: This was a cross-sectional descriptive survey of randomly selected primary care patients and physicians in eight primary care internal medicine clinics in the eastern and midwestern United States. Quantitative questionnaires were used to elicit subjects' demographic characteristics, and their opinions regarding the timing, content, and location of discussions about advance directives. Results: The 883 subjects included 329 adult outpatients, 282 resident physicians, and 272 practicing physicians. Physician and patient response rates were 75% and 76%, respectively. Patients felt that the discussion should occur earlier than did the physicians: at an earlier age, earlier in the natural history of disease, and earlier in the patient-physician relationship. Most subjects agreed it was the physician's responsibility to initiate the discussion. Conclusion: We defined a discrepancy between the preferences of primary care patients and physicians regarding the timing of the discussion about advance directives. We propose physician education regarding patient preferences as the most effective way to accomplish the goal of improving the frequency and quality of discussions about advance directives. (Arch Intern Med. 1995;155:1025-1030)

Do resident and staff physicians differ in the types and costs of antihypertensive drugs they select?

To compare the types and costs of drugs prescribed by resident and staff physicians treating patients with uncomplicated essential hypertension. Cross-sectional study, using a computer-based medical record database. Primary care internal medicine clinic in a large teaching hospital. Hypertensive patients seen by ten postgraduate year-1 (PGY-1) and PGY-2 primary care internal medicine residents and four staff physicians practicing in the same clinic. The types and costs of antihypertensive drugs prescribed for the patients treated by resident and staff physicians were compared. A larger proportion of patients of resident physicians than of staff physicians were treated with calcium channel blockers [19(15%) vs. 40(4%), p less than 0.001]; residents prescribed thiazide diuretics less frequently and beta-blockers more frequently than did staff physicians, although these differences were not significant. The estimated average wholesale price of antihypertensive drugs for patients cared for by residents was 35% higher than that for patients cared for by staff physicians ($0.73 vs. $0.54, p = 0.048). This difference was not fully explained by differences in practice composition. Resident physicians in this study selected more expensive medications to treat hypertension than did their faculty preceptors, even when differences in practice composition were considered.

Type a Personalty: Hispanic and Anglo Diabetes and Cardiovascular Disease

Type A personality among Anglo and Hispanic diabetes and cardiovascular disease patients was assessed. The specific objectives were to relate differences in Type A personality to Anglo and Hispanic ethnicity and to diabetes and cardiovascular diseases — hypertension and heart disease. The subjects for this research were consecutive patients selected from the patient population of a primary care internal medicine clinic affiliated with the University of California, Irvine Medical Center. A total of 162 currently active diabetes and cardiovascular disease patients and a comparison group of 74 patients who did not have diabetes and cardiovascular disease were included. Type A personality was measured by the 10 item Framigham Type A Questionnaire.

Evaluation of a limited drug formulary in an adult internal medicine clinic

The utility of a 30-drug, limited formulary in an adult internal medicine, ambulatory-care clinic was investigated. The formulary was developed using a mail survey of a random sample of members of the ASHP Ambulatory Care Pharmacy Practice Special Interest Group. The consensus formulary comprised the 30 most frequently recommended drugs; the utility of the formulary was then tested by chart review in a primary-care internal medicine clinic. Over a two-month period, the charts of alternating patients were reviewed daily; patient data collected included demographic information and prescribed drug therapy. A panel of two physicians and one pharmacist reviewed each patient's data and determined the appropriateness of drug treatment. If an agent was prescribed that was not on the consensus formulary, the panel determined whether an appropriate formulary agent could have been prescribed. Of the prescribed drug orders, 57.8% were for agents in the consensus formulary; by including patients who could have received formulary drugs appropriately, 73.7% of all prescription orders were or could have been for formulary drugs. Age, race, and sex of patients had no significant effect on utility of formulary agents. Had the 30 drugs most commonly prescribed in this clinic been in the formulary, 82.6% of all prescription orders would have been covered. This approach to establishing a new formulary and selecting drugs for inclusion is potentially useful.