Practices Of Primary Care Physicians Research Articles

Organization of Primary Care Practice for Providing Energy Balance Care

Primary care physicians (PCPs) may not adequately counsel or monitor patients regarding diet, physical activity, and weight control (i.e., provide energy balance care). We assessed the organization of PCPs' practices for providing this care. The study design was a nationally representative survey conducted in 2008. The study setting was U.S. primary care practices. A total of 1740 PCPs completed two sequential questionnaires (response rate, 55.5%). The study measured PCPs' reports of practice resources, and the frequency of body mass index assessment, counseling, referral for further evaluation/management, and monitoring of patients for energy balance care. Descriptive statistics and logistic regression modeling were used. More than 80% of PCPs reported having information resources on diet, physical activity, or weight control available in waiting/exam rooms, but fewer billed (45%), used reminder systems (<30%), or received incentive payments (3%) for energy balance care. A total of 26% reported regularly assessing body mass index and always/often providing counseling as well as tracking patients for progress related to energy balance. In multivariate analyses, PCPs in practices with full electronic health records or those that bill for energy balance care provided this care more often and more comprehensively. There were strong specialty differences, with pediatricians more likely (odds ratio, 1.78; 95% confidence interval, 1.26-2.51) and obstetrician/gynecologists less likely (odds ratio, 0.28; 95% confidence interval, 0.17-0.44) than others to provide energy balance care. PCPs' practices are not well organized for providing energy balance care. Further research is needed to understand PCP care-related specialty differences.

わが国のプライマリ・ケア医の定期接種および任意接種ワクチンの接種状況, 接種推奨割合および接種推奨の障壁

わが国のプライマリ・ケア医の定期接種および任意接種ワクチンの接種状況, 接種推奨割合および接種推奨の障壁

Knowledge, attitude and practice of primary health care physicians in Aseer region regarding obesity

Background: Obesity is one of the most common chronic diseases that could be managed at PHCC settings. Objectives: The objective of this study was to explore knowledge, attitudes, and practice of PHCC physicians in Aseer region, regarding obesity. Materials and Methods: This cross-sectional study was conducted among physicians working at PHCC in 2012. In order to achieve the objectives of this study, the investigators designed a questionnaire which composed of three parts namely; sociodemographic data, knowledge related questions, attitude related questions, practice related questions in addition to some questions related to infrastructures, and barriers facing management of obesity at PHCC. Questionnaire was distributed to all PHCC doctors using post. Data entry and statistical analysis was carried out using SPSS version 21. Results: The total number of doctors responded was 294 out of 339, giving a response rate of (87%). Mean age of participants was 38 year, male represented 63%, 61% had no post MBBS qualification and one third are working in big cities. More than 50% of centers were having registers, guidelines and screening program for obesity. The most common encountered barriers to care for obesity at PHCC were lack of (time, health education materials, guideline and referral system). Most of physicians showed good attitude regarding management of obesity compared to knowledge which was inadequate as reflected by total knowledge score which was less than 7 points among 64% of participants. More than half of participants reported that they gave advices about the roles of diet, exercise in management of obesity to their clients. Conclusion: This study revealed that PHCCs in Aseer region need adequate infrastructures to care for obese patients while PHCC doctors are in need of training to improve their knowledge and develop their skills in order to introduce good care for their obese patients.

Knowledge, attitudes, and practices of public sector primary health care physicians of rural north karnataka towards obesity management.

Introduction:Obesity is a risk factor for cardiovascular disease (CVD), diabetes mellitus (DM), and hypertension (HTN). In an era of rapidly growing prevalence of obesity, it is important to explore the current knowledge, attitude, and practices of primary care physicians.Materials and Methods:Study participants were medical officers (MOs) of primary health centers in three districts of North Karnataka. The questionnaire was developed by a review of literature in the field and validated with five participants for scope, length, and clarity.Results/Discussion:Of the 102 participants, only 15% were aware about the burden of obesity in India. HTN, DM, and CVD were indicated as comorbidities by 73, 78, and 60 participants, respectively. Only 25 and 12 participants indicated appropriate body mass index (BMI) cut-off values for overweight and obesity diagnosis. Of the 102 participants, 54 were not aware of the guidelines for obesity management. Practices and attitudes of the participants were encouraging. Nearly all of them felt that the adults with BMI within the healthy range should be encouraged to maintain their weight and, three-fourth of them agreed that most overweight persons should be treated for weight loss and small weight loss can achieve major medical benefit. However, nearly half of the participants’ responses were stereotypical as they felt only obese and overweight with comorbidities should be treated for weight loss. Two-thirds of them use BMI to diagnose overweight/obese and nearly all of them advice their patients to increase physical activity and restrict fat. Most of the participants were advising their patients to restrict sugar intake, increase fruits and vegetable consumption, reduce red meat, and avoid alcohol consumption.Conclusion:Present study exposed the lack of knowledge regarding obesity. However, practices and attitudes of the participants were promising. There is a need of in-service training to MOs to further improve their knowledge and practices towards management of obesity.

Relational Dynamics and Health Economics

Primary care physicians' and allied healing professionals are overwhelmed with greater demands to provide complex care within business structures that either mandate high volume or exorbitant fees for service in order to support healthcare needs or sustain their livelihood. Statistics within the USA note that 40 to 50 percent of primary care physicians practice consists of complicated care. There are continued decreases within the USA of medical doctors who enter general practice and most choose to enter specialties where they are able to dictate their hours of availability and are reimbursed at a higher rate for services. The exception lies in psychiatry and pediatrics, where there is a shortage of providers and low fees for service. Models that have been proposed to alleviate issues related to these shortages include models of integrated health care, where physicians provide holistic care or partner seamlessly with others to provide total care at a single location. Physician extenders have been developed as an alternative where Master's Level Nurses and Physician Assistants are allowed to practice in the same setting and under the supervision of the licensed physician to deliver care. The intent of the physician extender is to allow the physician to spend greater time with more complicated cases and for the assistants to provide routine care. The issue becomes differentiating when a patient presents with a routine issue but actually requires complex interventions. When traditional physical medicine is combined with a need for psychological counseling the needs are complex, and medical doctors or physician extenders are provided with only a three month rotation in psychological diagnosis and interventions. Both socialized non-socialized medicine do not have a practice model in which they provide adequate care and holistic healing. This paper proposes a new model of providing holistic healthcare based upon relational dynamics in an economically sound manner.

Knowledge, Attitudes and Practices of Primary Care Physicians in the Franche‐Comte Region (France) Regarding the Risk of Rabies

Rabies remains a public health concern and is associated with a mortality rate of nearly 100%. An observational survey was undertaken in 2010 to assess the knowledge, attitudes and practices of primary care physicians (PCPs) in our area regarding the risk of rabies. Standardized questionnaires were sent to a random sample of 400 PCPs practicing in the Franche-Comté region (eastern France), requesting their voluntary and anonymous participation. The questionnaires requested socio-demographic details and self-evaluation. Seven clinical situations were selected to assess the attitudes of physicians. The response rate was 38.5%. Most of the PCPs were based in rural and semi-rural areas, 76% knew where their nearest rabies centre was located and 75% of them claimed their knowledge of the risk of rabies was poor. While most of them (>80%) knew which animals transmitted the disease as well as the severity criteria for bites, only 12% knew that there was no contraindication for the rabies vaccine in the event of exposure to the disease. Responses to the seven clinical situations showed that most of them did not know the precise indication for the rabies vaccine and rabies immunoglobulin. Primary care physicians are usually aware of the risk of rabies, but their knowledge of how to manage rabies exposure and prevention often requires updating. The health authorities should provide more detailed information to PCPs and to the general population about the risk of rabies.

C3-4: Primary Care Physician Efficiency in Handling Patient Secure Email and the Impact on Patient Communication and Access

Background/Aims All Kaiser Permanente regions have implemented secure email functionality. Regional policies, workflows, and provider best practices have been established regarding secure email encounters with patients. This Phase I study explores effective practices of primary care physicians (PCPs) handling email traffic with patients, provides evidence regarding current secure email workflow and volumes, and estimates physician workloads related to daily secure email encounters with patients.

Improving Colorectal Cancer Screening in Family Medicine: An Oklahoma Physicians Resource/Research Network (OKPRN) Study

The purpose of this study was to describe colorectal cancer screening (CRCS) practices across a variety of primary care clinics and identify the methods used by primary care physicians (PCPs) with higher rates of CRCS ("exemplars"). Physician questionnaires, structured interviews, medical record abstractions, and practice observations were conducted for 48 PCPs in 25 practices within a regional practice-based research network followed by secondary in-depth interviews to further investigate the practices of PCPs in the top quartile of CRCS rates ("exemplars"). We abstracted 3596 medical records (mean of 75 records per PCP). Overall, exemplars had higher CRCS rates (median, 57.2% vs. 27.6%; P < .001). Patients of exemplars had higher screening rates for fecal occult blood testing (FOBT) and colonoscopy but not for flexible sigmoidoscopy or double-contrast barium enemas. Exemplars adopted few of the system-based innovations proposed by researchers to improve CRCS. Colonoscopy was promoted as the preferred CRCS method. FOBT was recommended for patients who could not afford or did not want colonoscopy. Flexible sigmoidoscopy or barium enemas were rarely recommended. Exemplars used brief CRCS promotion scripts that informally paralleled theory-driven counseling techniques. Experienced PCPs use brief CRCS promotion scripts including counseling techniques that improve CRCS performance. Future research should be directed toward whether these techniques can be used to create an intervention aimed at PCPs to improve CRCS.

The State of Readiness of Lagos State Primary Health Care Physicians to Embrace the Care of Depression in Nigeria

Globally there is a huge treatment gap for common mental disorders such as depression. Key to improving access to treatment will be the attitudes held towards depression by those physicians who work in Primary Care. This study aimed to explore Lagos State's Primary Care Physicians' attitudes towards depression and their views regarding their current working practices. A survey of 41 (82%) Primary Care Physicians in Lagos State who, after written consent, completed the Depression Attitude Questionnaire which assessed their knowledge and attitude towards the causes, consequences and treatment of depression. The largest part of the sample (37.5%) estimated that between 5 and 10% of the patients they saw over a 3 months period would have depression while one in four perceived rates of depression seen to be between 31 and 40%. Close to half (40%) of them felt that fewer than 5% of these depressed patients they saw would need antidepressants and a large part (82.9 %) of them agreed that becoming depressed is a way that people with poor stamina deal with life difficulties. About half (41.6%) of them believed it was not rewarding to look after depressed patients. Our study suggests that the current knowledge, attitudes and practices of most Lagos State primary health care physicians may be a barrier to patients with depression accessing appropriate care.

Pre‐travel Consultation: Evaluation of Primary Care Physician Practice in the Franche‐Comté Region

Primary care physicians (PCP) are first in line to provide adequate pre-travel medical advice. Little data are available on the content of pre-travel PCP consultations in France. We undertook an observational survey to assess the level of specific knowledge among PCPs on health advice, vaccinations, and malaria prophylaxis. Standardized questionnaires were sent to a random sample of 400 PCPs practicing in the Franche-Comté regions (eastern France) who were asked to complete and return it on a voluntary and anonymous basis. The questionnaire requested sociodemographic details, practice-related characteristics, and proposed three clinical situations with multiple choice questions (MCQ). To identify factors associated with a higher level of specific knowledge in travel medicine, results were studied by uni- and multivariate analyses. An overall score was calculated based on the MCQ answers and a motivation score was calculated based on parameters such as frequency and developments in pre-travel consulting at the practice, PCPs' personal experience as travelers, and the formal agreement of PCPs to administer yellow fever vaccination. The response rate was 37.5%, with 150 questionnaires returned completed and suitable for analysis. After multivariate logistic regression, the three variables associated with a higher score were: proximity of a vaccination center (p = 0.001), motivation score (p = 0.004), and absence of request for expert advice on malaria prophylaxis (p = 0.007). PCPs play an important role in travel medicine. This study showed that their high level of knowledge in travel medicine was mostly linked to their motivation to practice in this specialized discipline.

Improved Cost, Health, and Satisfaction With a Health Home Benefit Plan for Self-Insured Employers and Small Physician Practices

We compared the impacts on total costs, health, and satisfaction among 615 adults enrolled 2 years in an employer's health home benefit plan to their baseline year in a standard preferred provider organization plan. The new plan combined strong continuity care incentives with nurse coaching support. After 24 months, total medical costs were 23% lower than the baseline year, biometric measures improved for more than 85% of members, and patient satisfaction exceeded 85%. Emergency department visits decreased by 16% and hospital days decreased by 48%. Health home benefit plans engaging small primary care physician practices and members in coordinated continuity care can deliver high value.

Knowledge and Practice of Primary Care Physicians in Management of Gastroesophageal Reflux Disease

Knowledge and Practice of Primary Care Physicians in Management of Gastroesophageal Reflux Disease

An Analysis of the Effects of Health Insurer Monopsony Power on Primary Care Physician Practices

Consolidation of health insurers has generated significant concern that insurers are using monopsony power. This paper ascertains if monopsony power affects physician markets for primary care physicians. Physicians change having increased willingness to accept new Medicare patients, perception of Medicare reimbursement inadequacy and change volume of physician services in more concentrated insurer markets. However, physicians also have a lower percentage of practice revenues originating from private payers, increased levels of acceptance of new Medicaid recipients, and reduced perception of Medicaid payment inadequacy. Insurer concentration also leads physicians to integrate into multi-physician practices, affiliate with hospitals, and accept salaried financial arrangements

Varicella Zoster with Extended Prodrome: A Case Series

BackgroundTraditionally, varicella zoster (herpes zoster) is believed to have a prodrome of 1-3 days. The objective of our article is to emphasize the importance of including herpes zoster in the differential diagnosis of unilateral pain syndromes without vesicular lesions present for >3 days. Methods/ResultsWe report a case series from one primary care physician's practice at a tertiary-care teaching hospital documenting herpes zoster prodromes of 6-18 days. ConclusionsOur findings expand the clinical picture of herpes zoster, which hopefully will lead to cases of improved diagnoses that translate into the timely and cost-effective implementation of appropriate treatment.

Primary Care and Behavioral Health Practice Size

We investigated the size profile of US primary care and behavioral health physician practices since size may impact the ability to institute care management processes (CMPs) that can enhance care quality. We utilized 2009 claims data from a nationwide commercial insurer to estimate practice size by linking providers by tax identification number. We determined the proportion of primary care physicians, psychiatrists, and behavioral health providers practicing in venues of >20 providers per practice (the lower bound for current CMP practice surveys). Among primary care physicians (n=350,350), only 2.1% of practices consisted of >20 providers. Among behavioral health practitioners (n=146,992) and psychiatrists (n=44,449), 1.3% and 1.0% of practices, respectively, had >20 providers. Sensitivity analysis excluding single-physician practices as "secondary" confirmed findings, with primary care and psychiatrist practices of >20 providers comprising, respectively, only 19.4% and 8.8% of practices (difference: P<0.0001). In secondary analyses, bipolar disorder was used as a tracer condition to estimate practice census for a high-complexity, high-cost behavioral health condition; only 1.3-18 patients per practice had claims for this condition. The tax identification number method for estimating practice size has strengths and limitations that complement those of survey methods. The proportion of practices below the lower bound of prior CMP studies is substantial, and care models and policies will need to address the needs of such practices and their patients. Achieving a critical mass of patients for disorder-specific CMPs will require coordination across multiple small practices.

Lack of Association of OPRM1 Genotype and Smoking Cessation

Previous studies have reported an association between μ-opioid receptor (OPRM1) genotype and smoking cessation, with some evidence that the strength of this association depends on dose of nicotine replacement therapy (NRT). We examined whether a single-nucleotide polymorphism in the OPRM1 gene is associated with cessation and whether this variant moderates the effects of higher doses of NRT on abstinence. Participants were recruited from the practices of primary care physicians in the United Kingdom. Patients smoking an average of at least 10 cigarettes a day, who wanted to quit and were 18 years or older were eligible for inclusion. A total of N = 633 participants were recruited into the original trial, of whom complete data for pharmacogenetic analyses were available on n = 598. Logistic regression was used to test for the effects of OPRM1 genotype and NRT dose, including the genotype × dose interaction term, on smoking status at 4-week, and 26-week follow-up. Analyses were adjusted for potential confounders. There was no evidence of a genotype effect at either follow-up, and no evidence of a genotype × dose interaction effect. OPRM1 genotype may not affect the likelihood of smoking cessation, and it may not influence response to high- versus low-dose NRT. OPRM1 may have at most only a modest role in explaining cigarette smoking and cessation.

Development and integration of pharmacist clinical services into the patient-centered medical home

To describe the development of pharmacist clinical services within a primary care physician practice using a standardized business plan, the extent of clinical pharmacy service integration into the patient-centered medical home (PCMH), and the clinical changes in the pharmacist's patient cohort. A two-physician primary care/occupational care practice in Pittsburgh, PA, from May 2007 to December 2011. Pharmacist-led clinic receives physician referrals for medication management, adherence, and disease management services. Pharmacist practice in a primary care setting with emphasis on integration of clinical services into the medical home model designed by the American Academy of Family Physicians. Characterization of the patient's pharmacist and services provided by the pharmacist. Glycosylated hemoglobin (A1C), body mass index (BMI), low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, total cholesterol, triglycerides, and blood pressure. The top five primary referral reasons were diabetes self-management, weight management, medication adherence, hypertension, and dyslipidemia management. Improvements in clinical parameters were demonstrated for lipids and A1C at 1 and 2 years after baseline. Statistically significant improvements in BMI also were observed. The pharmacist developed and integrated clinical services into a primary care practice, became an integral member of the clinical team in the two-physician PCMH, and improved patient outcomes.

The operative management of patella malalignment.

Management of patellofemoral joint pathology is challenging as a result of the unique and complex organization of static forces and dynamic factors contributing to its functional capacity. Anterior knee pain is a common musculoskeletal complaint seen daily in the practices of primary care physicians, rheumatologists, and orthopedic surgeons. The key to successful treatment lies not only in the correct diagnosis of a chondral defect, but more importantly, in the accurate identification of associated pathomechanical factors. Appreciating the pathoanatomic basis of the disease and addressing imbalances and anatomical abnormalities should guide treatment.Despite the complexity of the interplay of various components it is essential to attempt to describe patellar malalignement as a clinical entity in order to proceed with appropriate surgical management and successful outcomes. The goals of patellofemoral re- alignment surgery should be to create both a stable environment for optimal extensor mechanism performance and an appropriate load transmission for optimal cartilage wear and joint loading. In the context of this article we will review the operative management of patellofemoral malalignment; the indications for surgery, the different techniques available and the evidence regarding their effectiveness.A large number of procedures have been employed and they have all undergone various modifications over the course of the years. The majority of publications are retrospective series in poorly defined population groups. There are significant methodological inconsistencies and as a result there is lack of strong evidence base for the majority of these procedures.

Federally Qualified Health Centers and Private Practice Performance on Ambulatory Care Measures

The 2010 Affordable Care Act relies on Federally Qualified Health Centers (FQHCs) and FQHC look-alikes (look-alikes) to provide care for newly insured patients, but ties increased funding to demonstrated quality and efficiency. To compare FQHC and look-alike physician performance with private practice primary care physicians (PCPs) on ambulatory care quality measures. The study was a cross-sectional analysis of visits in the 2006-2008 National Ambulatory Medical Care Survey. Performance of FQHCs and look-alikes on 18 quality measures was compared with private practice PCPs. Data analysis was completed in 2011. Compared to private practice PCPs, FQHCs and look-alikes performed better on six measures (p<0.05); worse on diet counseling in at-risk adolescents (26% vs 36%, p=0.05); and no differently on 11 measures. Higher performance occurred in ACE inhibitors use for congestive heart failure (51% vs 37%, p=0.004); aspirin use in coronary artery disease (CAD; 57% vs 44%, p=0.004); β-blocker use for CAD (59% vs 47%, p=0.01); no use of benzodiazepines in depression (91% vs 84%, p=0.008); blood pressure screening (90% vs 86%, p<0.001); and screening electrocardiogram (EKG) avoidance in low-risk patients (99% vs 93%, p<0.001). Adjusting for patient characteristics yielded similar results, except that private practice PCPs no longer performed better on any measures. FQHCs and look-alikes demonstrated equal or better performance than private practice PCPs on select quality measures despite serving patients who have more chronic disease and socioeconomic complexity. These findings can provide policymakers with some reassurance as to the quality of chronic disease and preventive care at Federally Qualified Health Centers and look-alikes, as they plan to use these health centers to serve 20 million newly insured individuals.

The Female Athlete Triad

Background. The Female Athlete Triad (Triad) is characterized by negative energy balance, disordered menstrual cycles, and low bone mineral density. The understanding and practices of primary care physicians (PCPs) regarding the Triad and the benefit of an educational intervention were assessed. Methods. PCPs attending a regional conference were surveyed prior to, immediately after, and three months following the plenary lecture on the Triad. Surveys included knowledge about the components, diagnostics, treatment, clinician practice, and comfort level with regard to the Triad. Results. The pre-test survey was completed by 84 of 126 (67%) attendees. The lecture increased from 53% to 98% the proportion of PCPs who identified the three domains of the Triad. Knowledge scores improved over the course of the lecture (from 3.4 to 5.1, p &lt; 0.05), particularly regarding Triad components (effect size = 1.2) and treatment (effect size = 1.6) with only small gains in diagnostic knowledge (effect size = 0.1 to 0.3). The three-month follow-up survey, completed by only seven clinicians (8%), suggested good retention of knowledge though little practice changes. Conclusions. A 50-minute educational session improved knowledge about the Triad. Particular improvement was noted in understanding the underlying etiology and treatment.