Involvement Of Primary Care Physicians Research Articles

Survivorship care after breast cancer treatment – Experiences and preferences of Australian women

Follow-up care after breast cancer treatment is becoming more complex as it attempts to address the long-term needs of an increasing number of survivors. Workforce issues in oncology challenge the sustainability of current specialist-based care. This study explores survivors’ experiences with follow-up care and attitudes to alternative models including a tailored survivorship care plan and involvement of primary care physicians and breast care nurses. Twenty women across Australia participated in semi-structured telephone interviews. All continued to attend follow-up visits with a specialist oncologist and reported a high level of satisfaction with care. Participants described a strong reliance on their specialist but were open to an increased role for their primary care physician in a shared model of care. Communication between multidisciplinary team members was perceived as an ongoing problem and there was enthusiasm for a patient-held written survivorship care plan to address this, and to meet information needs.

Type 2 Diabetes Care and Insulin Intensification

The purpose of this study was to investigate the opinions of primary care physicians (PCPs) and diabetes specialists on their perceived role in tackling type 2 diabetes (T2D) and the challenges they face, particularly regarding insulin intensification. Six hundred physicians from Germany, Japan, Spain, Turkey, the United Kingdom, and the United States were recruited to complete an online survey. Screening criteria included T2D patients seen per week (Europe/Japan: all ≥ 2; United States: PCPs ≥ 5; specialists ≥ 10) and years in practice (3-30 years). Most physicians had seen an increase in TD2 patients in the past 5 years, and almost all agreed that the burden of diabetes is increasing. Notable proportions of PCPs never initiate/modify insulin and never/rarely intensify insulin. Main barriers to insulin intensification cited were lack of experience and lack of time to educate patients. Better collaboration between primary and secondary care was considered one of the most important factors in improving insulin treatment of T2D. PCPs are less involved in the initiation and intensification of insulin than specialists; however, all physicians appreciate the need for increased PCP involvement. A multidisciplinary approach that includes using the skills of diabetes educators will assist physicians in improving management of T2D.

Recent initiatives on guidelines implementation: KT in primary care

In Canada, numerous initiatives have been developed in the recent years to improve guidelines implementation in respiratory care. Following the Canadian Thoracic Society (CTS) 1999 Canadian Asthma Consensus Guideline (CACG), efforts have been devoted to better disseminate this document and foster its implementation. This included among others, the production of a series of publications, development of a web-site, mailings of key messages to primary care physicians, interactive workshops and integration of CACG recommendations in educational programs. In the past, Canadian respiratory health guidelines have been produced and disseminated according to various agendas and methods, but in the last few years, the CTS has decided to develop a common body, the Canadian Respiratory Guidelines Committee (CRGC). The goal of the CRGC is to produce, disseminate, help implement and evaluate Canadian respiratory guidelines according to uniform methods and in a collaborative fashion, with a common annual agenda [1]. The methods used to produce and assess the performance of those guidelines are described in the publication by Gupta et al. [2]. Hopefully, this new strategy will allow a better use of resources and a more efficient translation process. Initiatives aimed at improving guideline implementation have also been developed and a specific Dissemination and Implementation Subcommittee has been formed to address this. A large scale project, the “Guidelines Implementation in Primary Care” (GIPC) study, based on quality circles and mentorship for primary care physicians (PCP) and involving interactive sessions and the use of practice tools had been developed but faced difficulties in regard to physicians recruitment, stressing the challenges associated in the involvement of busy PCPs is such studies. Various other means of contributing to guidelines implementation are presently considered. Documents and tools to facilitate the translation of guidelines can be found at www.respiratoryguidelines.ca. There is, therefore, a need to promote implementation initiatives according to the most effective methods recognized and to develop innovative strategies to improve the translation of guidelines recommendations, while considering the cost-effectiveness of these interventions in addition to the needs and motivations of the targeted groups. This is also one of the key mandates of the recently developed Laval University Chair on Knowledge Transfer, Education and Prevention in Respiratory and Cardiovascular Health, and various means of translating current cardio-respiratory guidelines are being developed and will soon be available on the site www.coeurpoumons.ca. Finally, numerous other asthma guidelines implementation initiatives have been proposed in many Canadian provinces in the last two decades (the reader is invited to consult their web site at http://www.lung.ca/about-propos/provincial-provinciales_e.php), and additional efforts are currently devoted to improving the effectiveness of such interventions. More recently, the National Lung Health Framework [3] has been developed, and should help address many of the remaining care gaps and target populations most in need of such interventions. The “Framework” is an action plan developed by and for a wide range of stakeholders working to improve lung health in Canada, using a collaborative approach to the prevention and management of respiratory disease. Finally, many educational and support networks such as the Canadian Network for Respiratory Care (http://www.cnrchome.net/), the Quebec Asthma and COPD Network (http://rqam.ca/), patient support groups and various other organizations, are contributing to the respiratory guidelines implementation through their educational programs. Hopefully, learning from the past, inspired by other countries’ initiatives and acting in collaboration with all stakeholders, we will be able to build and maintain a successful long-term guidelines implementation program that contributes to the improvement of respiratory health in Canada.

Has the Use of Physician Gatekeepers Declined among HMOs? Evidence from the United States

Since the mid-1980s, health maintenance organizations (HMOs) have grown rapidly in the United States. Despite initial successes in constraining health care costs, HMOs have come under increasing criticism due to their restrictive practices. To remain viable, this would seem to suggest that HMOs have to change at least some of these behaviors. However, there is little empirical evidence on how restrictive aspects of HMOs may be changing. The present study investigates one mechanism for constraining costs that is often associated with HMOs – the role of the primary care physician as a gatekeeper (e.g., monitoring patients’ use of specialist physicians). In particular, we estimate the effect of primary care physician involvement with HMOs on the percentage of their patients for whom these physicians serve as gatekeepers. We examine these relationships over two time periods: 2000-2001 and 2004-2005. Because physicians can choose whether and to what extent they will participate in HMOs, we employ instrumental variables (IV) estimation to correct for endogeneity of the HMO measure. Although the single-equation estimates suggest that the role of HMOs in terms of requiring primary care physicians to serve as gatekeepers diminished modestly over time, the endogeneity-corrected estimates show no changes between the two time periods. Thus, one major tool used by HMOs to constrain health care costs – the physician as gatekeeper – has not declined even in the era of managed care backlash.

The role of primary care physicians in advanced cancer care: perspectives of older patients and their oncologists.

To examine data from advanced cancer patients and their oncologists regarding patient age-related differences in patient and oncologist perspectives on involvement of primary care physicians (PCPs) in aspects of cancer management. Randomized controlled trial of a support intervention for patients with late-stage cancer treated in two teaching hospital-based cancer clinics caring for underserved populations. Three hundred fifty-seven patients who had an oncologist and PCP enrolled 2 to 3 months after an advanced cancer diagnosis. Sociodemographic data and structured interviews were used to assess patients' perceptions of PCP involvement in care discussions and decision-making and satisfaction with that involvement, oncologists' beliefs about how involved PCPs should be in these discussions and decisions, and their shared care practices. Older patients (>or=65) were more likely to have a PCP (P=.02). Patients reported a broad range of perceived PCP involvement and satisfaction with that involvement. Greater involvement was associated with greater satisfaction (P<.001). Half of oncologists reported themselves as PCP for more than 25% of their patients. Approximately half of oncologists reported that more older than younger patients had PCPs, yet only 20% reported differences in PCP involvement or in their communication with PCPs for older late-stage patients. Results support involvement of PCPs in advanced cancer care and demonstrate variable perspectives on PCP involvement. Matching patient preferences and practices may improve satisfaction. Clarification of elements in the partnership between patients, PCPs, and oncologists will inform efforts to optimally care for older patients with advanced cancer.

Disparities in Adequate Mental Health Care for Past-Year Major Depressive Episodes Among Caucasian and Hispanic Youths

Disparities in Adequate Mental Health Care for Past-Year Major Depressive Episodes Among Caucasian and Hispanic Youths

Disparities in Adequate Mental Health Care for Past-Year Major Depressive Episodes Among Caucasian and Hispanic Youths

Following efforts made in recent years to provide effective mental health treatments based on evidence-based guidelines, a working definition was developed in the literature detailing a minimum level of "adequate mental health care" for serious mental illness. However, little is known about racial or ethnic disparities in receipt of adequate mental health care for individuals affected with serious mental illness. The objective of this study was to examine disparities among Caucasian and Hispanic youths in receipt of adequate mental health care for past-year major depressive episodes. Data for this study were drawn from the 2005 National Survey on Drug Use and Health. The study sample was composed of 1,169 Caucasian youths and 316 Hispanic youths aged 12 to 17 with past-year major depressive episodes. The percentages of youths in the sample who received adequate mental health care for past-year major depressive episodes were estimated, and the correlates of receipt of adequate mental health care were examined. Thirty-four percent of the full sample received adequate mental health care for past-year major depressive episodes, but separate analyses indicated that adequate mental health care was received by a significantly higher proportion of Caucasian youths (36%) than Hispanic youths (27%). The odds of receiving adequate mental health care for past-year major depressive episodes for Caucasians were 1.55 times that of Hispanics (p=.01). Having Medicaid or coverage via the State Children's Health Insurance Program significantly increased the odds of receiving adequate mental care for past-year major depressive episodes for both Hispanics and Caucasians. As mental health problems of adolescents from diverse racial or ethnic backgrounds become more easily identified and a larger proportion of these groups is referred to mental health treatment services, it is important to examine the degree to which treatment should be tailored to engage and retain specific racial or ethnic groups so that they will receive the minimum of adequate mental health care.

The Role of Primary Care Physicians in Cancer Care

The demand for oncology services in the United States (US) is increasing, whereas a shortage of oncologists looms. There is the need for a better understanding of the involvement of primary care physicians (PCPs) in cancer care. To characterize the role of PCPs in cancer care, compare it with that of oncologists, and identify factors explaining greater PCP involvement in cancer care. National survey of physicians caring for cancer patients conducted by the Cancer Care Outcomes Research and Surveillance Consortium. 1694 PCPs; 1621 oncologists. Questionnaires mailed during 2005 and 2006 examined the participation of physicians in 12 aspects of care for cancer patients. Over 90% of PCPs fulfilled general medical care roles for patients with cancer such as managing comorbid conditions, chronic pain, or depression; establishing do-not-resuscitate status; and referring patients to hospice. Oncologists were less involved in these roles. Determining the treatment preferences of individual patients and deciding on the use of surgery were the only cancer care roles in which > or =50% of PCPs participated. Twenty-two percent of PCPs reported no direct involvement in cancer care roles while 19% reported heavy involvement. PCPs who were aged > or =50 years, were internists or geriatricians, taught medical students, saw more cancer patients, or experienced referral barriers fulfilled more roles. Rural practice location was not associated with greater PCP involvement in cancer care. PCPs across the US have an active role in cancer patient management. Determining the optimal interface between PCPs and oncologists in delivering and coordinating cancer care is an important area for future research.

Who’s in charge? Challenges in evaluating quality of primary care treatment for low back pain

Low back pain (LBP) is a common condition with frequent health care visits and work disability. Quality improvement efforts in primary care focused on guidelines adherence, provider selection and education, and feedback on appropriateness of care. Such efforts can only succeed if a health care provider is in charge of care over a substantial period. This study was conducted to provide insights about actual patterns of provider involvement in LBP care and implications for quality evaluation. Established primary care patients with occupational LBP and health care covered by a workers' compensation insurer were selected. Primary care physician (PCP) involvement was examined relative to overall health care utilization. Four methods of classifying PCP involvement were used to assess the association between PCP involvement and health care and work disability outcomes over a 2-year follow-up period. Primary care physician was rarely the sole provider during episodes of occupational LBP. PCP was the initial non-emergency room provider in 55% of cases, and was the most prevalent provider during at least one episode of care in 45% of cases. Different methods of classification led to different conclusions about the association between PCP involvement and work disability or number of health care visits. Multiple providers were involved throughout the clinical course of the small number of cases that accounted for most of the health care visits and work disability; in these cases, the role of PCP in care was difficult to determine. Administrative data alone are adequate for provider comparisons only in relatively simple cases. Provider comparisons based on initial treating provider likely overstate the importance of early care, particularly in more complex cases. For LBP, quality improvement models based on PCP-directed interventions or reinforcing guideline adherence may not impact outcomes. A patient-centred model may be necessary to achieve outcome improvements.

Concordancia en el estudio de retinografías en diabéticos: oftalmólogos vs médicos de familia

To assess the extent of agreement in the evaluation of non-mydriatic retinographies of diabetic patients among ophthalmologists and a group of primary care physicians with previous training. The study was divided in two phases. In the first phase, the four participants were instructed in the interpretation of retinographies. The second phase involved the evaluation of 1000 images of 200 patients, 100 without retinopathy and 100 with signs of diabetic retinopathy. The four participants had to decide if the images did or did not show evidence of diabetic retinopathy. Kappa index was used to assess the extent of agreement. A percentage disagreement of 15% with a precision of 5% (+/-5%) with a confidence level of 95% was considered adequate. The percentage of coincident diagnoses among ophthalmologists and primary care physicians was between 89 and 97.5%. With respect to the assessment of the agreement, the kappa index was between 80 and 95%. In all cases the confidence interval was at least 85%. After an adequate training process, the reliability of evaluation of non-mydriatic retinographies of diabetic patients by primary care physicians was very high. This could allow the establishment of screening for diabetic retinopathy at the primary care level. Advantages of this system include a greater involvement of primary care physicians in the global management of diabetic patients and a lower demand for ophthalmic attention.

"Minimum Knowledge" Essential for Primary Care Physicians - Involvement of Primary Care Physicians in Medical Legislation

"Minimum Knowledge" Essential for Primary Care Physicians - Involvement of Primary Care Physicians in Medical Legislation

Stakeholders' Perspectives on the Recommendations of the President's New Freedom Commission on Mental Health

Stakeholders' Perspectives on the Recommendations of the President's New Freedom Commission on Mental Health

News and Notes

News and Notes

Barriers to breast cancer risk screening

1505 Background: The U. S. Preventive Services Task Force has recommended that physicians assess and discuss breast cancer risk with their female patients. With this recommendation comes the need to develop strategies for providing breast cancer risk-screening and a need to identify potential barriers to the successful implementation of a risk-screening strategy. Methods: A personalized breast cancer risk profile was offered to all women presenting for a screening mammogram at a community hospital. The profile included a Gail model estimate and analysis of family cancer history to detect hereditary breast cancer syndromes utilizing a pedigree assessment tool developed by the authors. Women with 5 year Gail estimates ≥ 1.66%, lifetime Gail estimate ≥ 15% or increased score with the pedigree assessment tool were considered at increased breast cancer risk. Women in the increased risk cohort received written notification of their risk status and were advised to undergo formal risk assessment either through a free consultation with an advanced practice nurse with expertise in cancer risk assessment or with their primary physician. We analyzed compliance with this recommendation over the 6 month period of time after subjects received the risk notification letter. Results: For the three month study period, 242 women met criteria for the increased risk cohort. Of these, 201 (83%) failed to follow through with the advanced practice nurse for formal risk assessment. Surveys were mailed to all 201 non-compliant subjects to identify reasons for non-compliance and 80 surveys were returned (40%). Reasons given for failure to follow- through with formal risk assessment included: self-perception of “average” breast cancer risk (75%), recent normal screening mammogram (55%), primary care physician had not referred them (18%), absence of breast symptoms (15%), and time constraints (15%). Only 11 subjects (14%) indicated that they had discussed risk results with their physician. Conclusions: The majority of women in our study who requested breast cancer risk estimates failed to act on that information. These results could have implications for design and implementation of a successful breast cancer risk-screening program, and point to the need for better patient education and involvement of primary care physicians in the risk assessment process. No significant financial relationships to disclose.

Physician Perspectives of Nurse Care Management Located in Primary Care Clinics

Care management has been suggested as a method to improve management of chronic disease, but its success can depend on the involvement of primary care physicians, especially with referral to care management. Our objective was to identify and characterize physicians' perspectives of care management in order to gain insight into the rationale for referral to care management. The study took place in primary care clinics within an integrated delivery system. Nineteen primary care physicians with varying levels of involvement with care management participated in the study. We performed a qualitative and quantitative analysis ofsemistructured interviews. Four referral patterns emerged that were related to physicians' recognition of care managers' abilities and how care managers were connected to their practice. Results from this study can be used to more effectively implement similar models of chronic disease management, where physician participation is a critical component for successful implementation.

Challenges in the Therapy of Secondary Hyperparathyroidism

Derangements in mineral metabolism are known to occur early in the course of chronic kidney disease (CKD). Recent clinical practice guidelines are designed to focus on the problem early in the course of kidney disease, when it is recommended to evaluate the levels of parathyroid hormone (PTH) and to try to intervene early if the levels are elevated. To begin early intervention for hyperparathyroidism in chronic kidney disease will require involvement of primary care physicians and other subspecialty groups to identify the patients at risk and begin to intervene with measures to control hyperparathyroidism and its consequences on mineral metabolism. It has recently been demonstrated that chronic kidney disease is a significant risk factor for vitamin D deficiency and since abnormalities in vitamin D metabolism are important in the generation of hyperparathyroidism, this is an issue that needs direct attention. Studies are needed to assess the effects of correcting this vitamin D deficiency in early CKD. As kidney disease progresses, efforts to control hyperparathyroidism will likely need to be intensified and several therapeutic options are available, such as phosphate binders, repletion of vitamin D, the use of active vitamin D sterols, or the use of vitamin D analogs. In addition, it is important to define the appropriate PTH values that need to be achieved to minimize complications on bone. Such studies are in progress at the present time to validate the current more specific PTH assays. Strict guidelines have been proposed for the management of bone and mineral metabolism in patients with CKD stage V on dialysis, and although these challenging recommendations were initially opinion-based, there is mounting evidence which provides confirmation of these targets as relevant. Treatment options for patients on dialysis involve the full spectrum of agents which include phosphate binders, active vitamin D sterols (often given parenterally), the use of calcimimetic agents, surgical parathyroidectomy, and evaluation of appropriate levels of dialysate calcium. Similar to early stages of CKD, studies are in progress to refine the PTH targets with the newer PTH assays. With increased focus on the complications of bone and mineral metabolism as part of the continuum of chronic kidney disease, and with a variety of new therapies available, it is anticipated that improved patient outcomes should be achievable in this patient group.

Switching to Gatekeeping: Changes in Expenditures and Utilization for Children

Gatekeeping has been a central strategy in the cost-containment initiatives of managed care organizations. Little empirical research describes the impact of switching into a gatekeeping plan on health care expenditures and utilization for children. To determine the likelihood of a parent with a chronically ill child enrolling in a health plan with gatekeeping, as well as the effects of gatekeeping on health care expenditures and utilization for children, especially those with chronic conditions. We followed a cohort of 1839 children who either voluntarily switched to a gatekeeping plan or remained in an indemnity plan from 1991 through 1994. Study participants were children of employees of a large hospital. The gatekeeping plan was virtually identical to the previous indemnity plan except for lower monthly employee contribution and the requirement for a primary care physician to preapprove subspecialty referrals. We determined the likelihood of a household containing a child with a chronic condition enrolling in the gatekeeping plan, as well as mean annual total, subspecialty, and primary care expenditures and utilization for all children and children with chronic conditions. Households switching to gatekeeping were less likely to have children with chronic illness (8% vs 15%). Total and subspecialty expenditures for all children decreased more in the gatekeeping group (53% and 59%, respectively) than in the indemnity group (11% and 6%, respectively). For children with chronic conditions, mean visits to subspecialists decreased 57% in the gatekeeping group but increased 31% in the indemnity group. Mean visits to primary care physicians decreased 23% in the gatekeeping group compared with 13% in indemnity group. Parents of children with a chronic condition were much less likely than other parents to switch to a gatekeeping plan. Switching to gatekeeping was associated with reduced visits to specialists but did not increase the involvement of primary care physicians in the management of children with chronic conditions. The implications of these findings for the health of children are unknown.

The Role of the Primary Care Provider in Preventing and Treating Alcohol Problems in Adolescents

Adolescents use alcohol more frequently and heavily than all other illicit drugs combined. Given the myriad health, developmental, and social problems associated with alcohol use, it is not surprising that the American Medical Association's Guidelines for Adolescent Preventive Services recommends that adolescents be asked annually about their use of alcohol, and those who report any use during the past year should be assessed further. However, routine alcohol screening of adolescents in primary care and emergency medical settings is not universally applied. In March 2000, the National Institute on Alcohol Abuse and Alcoholism of the National Institutes of Health and the Agency for Health care Research and Quality jointly sponsored a meeting entitled The Expanding Role of Primary Care in the Prevention and Treatment of Alcohol-Use Disorders. The purpose of the meeting was to bring together researchers, policymakers, clinicians, insurance providers, and medical education specialists to determine the best approaches to increase the involvement of primary care physicians and other health care professionals in screening and intervening for alcohol problems in their patients. The National Institute on Alcohol Abuse and Alcoholism and Agency for Health care Research and Quality believe that the evidence of efficacy for primary care involvement is compelling and are working together to promote the translation of these findings into clinical practice. The following article summarizes what is currently known about adolescent alcohol use and how it can be addressed in primary care settings. It provided the background for the meeting's focus on adolescent issues.

Primary care physician involvement improves participation in colorectal cancer screening

Primary care physician involvement improves participation in colorectal cancer screening

How should the obese patient be managed? Possible approaches to a national obesity management network.

There is clearly a need for novel approaches to obesity and its management. This has been addressed by the Czech Society for the Study of Obesity, which established a multi-level obesity management network in response to the increasing prevalence of obesity in the Czech Republic. This network includes obesity management centres attached to major teaching hospitals, combined with input from obesity specialists, other specialists, primary healthcare physicians and weight reduction groups. Such an obesity management system aims to provide appropriate diagnostic and treatment facilities for various degrees of obesity throughout the country. The proposed density of the obesity management network takes into account the limited resources in the healthcare system. The network is designed to overcome the current poor level of understanding of obesity and the lack of time and financial resources which have been the most significant barriers to more involvement of primary care physicians in obesity management. In order to implement this system, a comprehensive education programme on obesity was initiated with postgraduate courses for obesity specialists and with training for counsellors of weight reduction groups.