Survey Of Primary Care Providers Research Articles

Panel Workload Assessment in US Primary Care: Accounting for Non-Face-to-Face Panel Management Activities

An understanding of primary care provider (PCP) workload is an important consideration in establishing optimal PCP panel size. However, no widely acceptable measure of PCP workload exists that incorporates the effort involved with both non-face-to-face patient care activities and face-to-face encounters. Accounting for this gap is critical given the increase in non-face-to-face PCP activities that has accompanied electronic health records (EHRs) (eg, electronic messaging). Our goal was to provide a comprehensive assessment of perceived PCP workload, accounting for aspects of both face-to-face and non-face-to-face encounters. Internal medicine, family medicine, and pediatric PCPs completed a self-administered survey about the perceived workload involved with face-to-face and non-face-to-face panel management activities as well as the perceived challenge associated with caring for patients with particular biomedical, demographic, and psychosocial characteristics (n = 185). Survey results were combined with EHR data at the individual patient and PCP service levels to assess PCP panel workload, accounting for face-to-face and non-face-to-face utilization. Of the multiple face-to-face and non-face-to-face activities associated with routine primary care, PCPs considered hospital admissions, obstetric care, hospital discharges, and new patient preventive health visits to be greater workload than non-face-to-face activities such as telephone calls, electronic communication, generating letters, and medication refills. Total workload within PCP panels at the individual patient level varied by overall health status, and the total workload of non-face-to-face panel management activities associated with routine primary care was greater than the total workload associated with face-to-face encounters regardless of health status. We used PCP survey results coupled with EHR data to assess PCP workload associated with both face-to-face as well as non-face-to-face panel management activities in primary care. The non-face-to-face workload was an important contributor to overall PCP workload for all patients regardless of overall health status. This is an important consideration for PCP workload assessment given the changing nature of primary care that requires more non-face-to-face effort, resulting in an overall increase in PCP workload.

When to repatriate? Clinicians' perspectives on the transfer of patient management from specialty to primary care.

Subspecialty ambulatory care visits have doubled in the past 10 years and nearly half of all visits are for follow-up care. Could some of this care be provided by primary care providers (PCPs)? To determine how often PCPs and specialists agree that a mutual patient's condition could be managed exclusively by the PCP, and to understand PCPs' perspectives on factors that influence decisions about 'repatriation,' or the transfer of patient management to primary care. A mixed method approach including paired surveys of PCPs and specialists about the necessity for ongoing specialty care of mutual patients, and interviews with PCPs about care coordination practices and reasons for differing opinions with specialists. One hundred and eighty-nine PCPs and 59 physicians representing five medicine subspecialties completed paired surveys for 343 patients. Semi-structured interviews were conducted with 16 PCPs. For each patient, PCPs and specialists were asked, "Could this diagnosis be managed exclusively by the PCP?" Specialists and PCPs agreed that transfer to primary care was appropriate for 16% of patients, whereas 36% had specialists and PCPs who agreed that ongoing specialty care was appropriate. Specialists were half as likely as PCPs to identify patients as appropriate for transfer to primary care. PCPs identified several factors that influence the likelihood that patients will be transferred to primary care, including perceived patient preferences, limited access to physician appointments, excessive workload, inter-clinician communication norms, and differences in clinical judgment. We group these factors into two domains: 'push-back' and 'pull-back' to primary care. At a large academic medical center, approximately one in six patients receiving ongoing specialty care could potentially be managed exclusively by a PCP. PCPs identified several non-clinical factors to explain continuation of specialty care when patient transfer to PCP is clinically appropriate.

(136) Beliefs about prescribing opioids for chronic pain: survey of primary care providers

There is growing concern among primary care providers (PCPs) of medication misuse and noncompliance among chronic pain patients prescribed opioids for pain. This survey study is part of a larger investigation on improving provider confidence in managing chronic pain patients through the use of specialty support, risk assessment, and summary reports. Forty-five (N=45) primary care providers completed a packet of questionnaires about attitudes and concerns about opioids for chronic pain including the Concerns About Analgesic Prescription Questionnaire. The providers also completed background information, the General Health Questionnaire, and the Knowledge of OpioidsTest (KOT). Ages ranged between 27 and 64 (average 43 years), 58% were female, and 82% were Caucasian. In general, the PCPs showed adequate opioid knowledge on the KOT (averaging 17 of 25 items correct) and general health was unrelated to prescription attitudes. Most expressed concern about medication misuse (90%) and felt that managing chronic pain patients was stressful (84%). Most were worried about addiction (82%) and less than half felt that they were sufficiently trained in prescribing opioids (44%).Many also felt that theywere not satisfiedwith the support and communication they received from pain specialists in managing their chronic pain patients (67%). Younger providers felt more reluctant to prescribe opioids, experiencedmore stress in managing pain patients, had less overall confidence in managing pain patients, and worried more about dependence than older providers (p<0.05). Younger providerswere also less knowledgeable about opioids, but opioid knowledge was not found to be related to concerns about analgesic prescriptions. An ongoing study will continue to track providers and patients to help determine whether careful patient monitoring and incorporation of a structured opioid therapy protocol (risk assessment, periodic urine screens, and compliance checklists) will reduce opioid misuse within primary care. This survey was partially supported by a grant from Mallinckrodt.

Developing a toolkit for panel management: improving hypertension and smoking cessation outcomes in primary care at the VA.

BackgroundAs primary care practices evolve into medical homes, there is an increasing need for effective models to shift from visit-based to population-based strategies for care. However, most medical teams lack tools and training to manage panels of patients. As part of a study comparing different approaches to panel management at the Manhattan and Brooklyn campuses of the VA New York Harbor Healthcare System, we created a toolkit of strategies that non-clinician panel management assistants (PMAs) can use to enhance panel-wide outcomes in smoking cessation and hypertension.MethodsWe created the toolkit using: 1) literature review and consultation with outside experts, 2) key informant interviews with staff identified using snowball sampling, 3) pilot testing for feasibility and acceptability, and 4) further revision based on a survey of primary care providers and nurses. These steps resulted in progressively refined strategies for the PMAs to support the primary care team.ResultsLiterature review and expert consultation resulted in an extensive list of potentially useful strategies. Key informant interviews and staff surveys identified several areas of need for assistance, including help to manage the most challenging patients, providing care outside of the visit, connecting patients with existing resources, and providing additional patient education. The strategies identified were then grouped into 5 areas – continuous connection to care, education and connection to clinical resources, targeted behavior change counseling, adherence support, and patients with special needs.ConclusionsAlthough panel management is a central aspect of patient-centered medical homes, providers and health care systems have little guidance or evidence as to how teams should accomplish this objective. We created a toolkit to help PMAs support the clinical care team for patients with hypertension or tobacco use. This toolkit development process could readily be adapted to other behaviors or conditions.Trial registrationClinicalTrials.gov, NCT01677533

A Case Study of a Team-Based, Quality-Focused Compensation Model for Primary Care Providers

In 2011, Fairview Health Services began replacing their fee-for-service compensation model for primary care providers (PCPs), which included an annual pay-for-performance bonus, with a team-based model designed to improve quality of care, patient experience, and (eventually) cost containment. In-depth interviews and an online survey of PCPs early after implementation of the new model suggest that it quickly changed the way many PCPs practiced. Most PCPs reported a shift in orientation toward quality of care, working more collaboratively with their colleagues and focusing on their full panel of patients. The majority reported that their quality of care had improved because of the model and that their colleagues' quality had to. The comprehensive change did, however, result in lower fee-for-service billing and reductions in PCP satisfaction. While Fairview's compensation model is still a work in progress, their early experiences can provide lessons for other delivery systems seeking to reform PCP compensation.

Use and satisfaction with key functions of a common commercial electronic health record: a survey of primary care providers

BackgroundDespite considerable financial incentives for adoption, there is little evidence available about providers’ use and satisfaction with key functions of electronic health records (EHRs) that meet “meaningful use” criteria.MethodsWe surveyed primary care providers (PCPs) in 11 general internal medicine and family medicine practices affiliated with 3 health systems in Texas about their use and satisfaction with performing common tasks (documentation, medication prescribing, preventive services, problem list) in the Epic EHR, a common commercial system. Most practices had greater than 5 years of experience with the Epic EHR. We used multivariate logistic regression to model predictors of being a structured documenter, defined as using electronic templates or prepopulated dot phrases to document at least two of the three note sections (history, physical, assessment and plan).Results146 PCPs responded (70%). The majority used free text to document the history (51%) and assessment and plan (54%) and electronic templates to document the physical exam (57%). Half of PCPs were structured documenters (55%) with family medicine specialty (adjusted OR 3.3, 95% CI, 1.4-7.8) and years since graduation (nonlinear relationship with youngest and oldest having lowest probabilities) being significant predictors. Nearly half (43%) reported spending at least one extra hour beyond each scheduled half-day clinic completing EHR documentation. Three-quarters were satisfied with documenting completion of pneumococcal vaccinations and half were satisfied with documenting cancer screening (57% for breast, 45% for colorectal, and 46% for cervical). Fewer were satisfied with reminders for overdue pneumococcal vaccination (48%) and cancer screening (38% for breast, 37% for colorectal, and 31% for cervical). While most believed the problem list was helpful (70%) and kept an up-to-date list for their patients (68%), half thought they were unreliable and inaccurate (51%).ConclusionsDissatisfaction with and suboptimal use of key functions of the EHR may mitigate the potential for EHR use to improve preventive health and chronic disease management. Future work should optimize use of key functions and improve providers’ time efficiency.

Acute kidney injury and its association with in-hospital mortality among children with acute infections

We investigated prevalence of acute kidney injury (AKI) at hospitalization and its association with in-hospital mortality among Ugandan children hospitalized with common acute infections, and predictors of mortality among AKI children. We enrolled 2,055 children hospitalized with primary diagnoses of acute gastroenteritis, malaria, or pneumonia. Serum creatinine, albumin, electrolytes, hemoglobin, and urine protein were obtained on admission. Participants were assessed for AKI based on serum creatinine levels. Demographic and clinical data were obtained using a primary care provider survey and medical chart review. Logistic regression was used to determine predictors of in-hospital mortality. A total of 278 (13.5%) of children had AKI on admission; for 76.2%, AKI was stage 2 (98/278) or stage 3 (114/278) defined as serum creatinine >2- or 3-fold above normal upper limit for age, respectively. AKI prevalence was particularly high in gastroenteritis (28.6%) and underweight children (20.7%). Twenty-five percent of children with AKI died during hospitalization, compared to 9.9% with no AKI (adjusted odds ratio (aOR) 3.5 (95% CI, 2.2-5.5)). In-hospital mortality risk did not differ by AKI stage. Predictors of in-hospital mortality among AKI children included primary diagnosis of pneumonia, aOR 4.5 (95% CI, 1.8-11.2); proteinuria, aOR = 2.1 (95% CI, 1.0-4.9) and positive human immunodeficiency virus (HIV) status, aOR 5.0 (95% CI, 2.0-12.9). Among children hospitalized with gastroenteritis, malaria, or pneumonia, AKI at admission was common and associated with high in-hospital mortality.

Preventing Dehydration-Related Hospitalizations: A Mixed-Methods Study of Parents, Inpatient Attendings, and Primary Care Physicians

The goal of this study was to identify the proportion of dehydration-related ambulatory care-sensitive condition hospitalizations, the reasons why these hospitalizations were preventable, and factors associated with preventability. A cross-sectional survey of primary care providers (PCPs), inpatient attending physicians, and parents was conducted in a consecutive series of children with ambulatory care-sensitive conditions admitted to an urban hospital over 14 months. Eighty-five children were diagnosed with dehydration. Their mean age was 1.6 years; most had public (74%) or no (17%) insurance, and were nonwhite (91%). The proportion of hospitalizations assessed as preventable varied from 12% for agreement among all 3 sources to 45% for any source. Parents identified inadequate prevention (50%), poor self-education (34%), and poor quality of care (38%) as key factors. PCPs identified parents providing insufficient home rehydration (33%), not visiting the clinic (25%), and not calling earlier (16%) as reasons. Inpatient attending physicians cited home rehydration (40%), delays in seeking care (40%), and lacking a PCP (20%) as contributors. Physicians (PCPs and inpatient attending physicians) were more likely than parents to describe the admission as inappropriate (75% vs 67% vs 0%; P < .01). Parental dissatisfaction with their child's PCP and a history of avoiding primary care due to costs or insurance problems were associated with significantly higher odds of preventable hospitalization. Up to 45% of dehydration-related hospitalizations may be preventable. Inadequate parental education by physicians, insufficient home rehydration, deferring clinic visits, insurance and cost barriers, inappropriate admissions, poor quality of care, and parental dissatisfaction with PCPs are the reasons that these hospitalizations might have been prevented.

Prospective cost–benefit analysis of a two-dimensional barcode for vaccine production, clinical documentation, and public health reporting and tracking

In the United States recording accurate vaccine lot numbers in immunization records is required by the National Childhood Vaccine Injury Act and is necessary for public health surveillance and implementation of vaccine product recalls. However, this information is often missing or inaccurate in records. The Food and Drug Administration (FDA) requires a linear barcode of the National Drug Code (NDC) on vaccine product labels as a medication verification measure, but lot number and expiration date must still be recorded by hand. Beginning in 2011, FDA permitted manufacturers to replace linear barcodes with two-dimensional (2D) barcodes on unit-of-use product labels. A 2D barcode can contain the NDC, expiration date, and lot number in a symbol small enough to fit on a unit-of-use label. All three data elements could be scanned into a patient record. To assess 2D barcodes’ potential impacts, a mixed-methods approach of time–motion data analysis, interview and survey data collection, and cost–benefit analysis was employed. Analysis of a time–motion study conducted at 33 practices suggests scanning 2D-barcoded vaccines could reduce immunization documentation time by 36–39s per dose. Data from an internet survey of primary care providers and local health officials indicate that 60% of pediatric practices, 54% of family medicine practices, and 39% of health departments would use the 2D barcode, with more indicating they would do so if they used electronic health records. Inclusive of manufacturer and immunization provider costs and benefits, we forecast lower-bound net benefits to be $310–334 million between 2011 and 2023 with a benefit-to-cost ratio of 3.1:1–3.2:1. Although we were unable to monetize benefits for expected improved immunization coverage, surveillance, or reduced medication errors, based on our findings, we expect that using 2D barcodes will lower vaccine documentation costs, facilitate data capture, and enhance immunization data quality.

Evaluation of Methods for Dissemination of Prostate Cancer Survivorship Guidelines: A Survey of Primary Care Providers

Objectives: To assess potential knowledge gaps between primary care providers (PCPs) and cancer specialists, Michigan Cancer Consortium guidelines were developed and disseminated statewide. We evaluated the impact of dissemination of these guidelines on PCP attitudes and beliefs regarding management of prostate cancer (PC) post-treatment sequelae. Methods: Guidelines were disseminated via hard-copy and web-link mailed to 12,000 Michigan PCPs in 2009, and via 5 CME presentations to 181 PCPs in 2010-2011. 132 initial surveys were collected from CME attendees and 549 follow-up surveys were received 20 months after the initial mailing. Results: Surveyed PCPs indicated erectile dysfunction (88%), incontinence (84%), anxiety (54%) and fear of the unknown (50%) as frequent post-treatment sequelae. A minority of PCPs (≤41%) felt “very comfortable” assessing PC patients for ten post-treatment sequelae at the initial survey, which increased by up to 27% on follow-up survey. 93% of PCPs that received guidelines by mail and CME presentation had incorporated them into practice, compared with 72% of PCPs that received guidelines solely by mailing. Similarly, a greater proportion reported practice pattern changes (65% vs. 34%, p = 0.0003). A higher proportion felt CME events (69% vs. 57%) and expert presentations (64% vs. 44%) were “very effective”, when comparing attendees and non-attendees. Conclusions: Guideline distribution resulted in increased comfort with survivorship issues and incorporation into the practices of the majority of PCPs surveyed. A greater impact was observed in PCPs that attended a CME presentation than in those that received guidelines only by mailing.

Caring for Alaska native prostate cancer survivors in primary care: A survey of Alaska Tribal Health System providers.

6126 Background: Little is known about the actual constraints of doing so in the distinctive geographic context of Alaska. We performed a survey of primary care providers (PCPs) within the Alaska Tribal Health System (ATHS) to learn more about their attitudes and practices surrounding prostate cancer (PC) survivorship care. Methods: We surveyed primary care physicians, nurse practitioners, and physician assistants practicing in the ATHS. We administered surveys to assess attitudes about PSA monitoring, responsibility for long-term surveillance, supporting emotional health and medical needs, their degree of confidence in managing patients on androgen deprivation therapy (ADT), as well as their comfort level in managing common side effects of treatment. Results: Of the 221 providers surveyed, 114 responded (52%). Most PCPs indicated a preference for annual PSA monitoring (69%), but several (27%) indicated monitoring every 6 months, and a few (4%) indicated monitoring every 24 months. Most (60%) thought PCPs should manage cancer surveillance, but many (40%) thought a specialist (urologist or medical oncologist) should perform that function. When asked about supporting patients’ emotional needs, PCPs indicated that support groups (63%) followed by survivorship clinics (16%) or on-site specialist visits (14%) were the most appropriate venues to address these concerns. Most respondents thought that medical needs of PC survivors could be addressed locally with appropriate specialty input (71%) or potentially through dedicated survivorship clinics (14%). Only 46% indicated being "moderately" or "very" confident managing ADT. Most PCPs indicated being moderately or very comfortable monitoring for recurrence (59%), managing erectile dysfunction (66%), addressing urinary incontinence (63%), and addressing emotional needs (61%). Conclusions: PCPs practicing in the ATHS express comfort with monitoring for PC recurrence, but express some concerns about the full range of issues in PC survivorship. Constructing cancer survivor care models in geographically dispersed and resource-limited contexts for Alaska Natives is an ongoing clinical and policy challenge.

Rural and Nonrural Differences in Providing Care for Children With Complex Chronic Conditions

To better understand the challenges faced by primary care providers in rural locations in providing care for children with complex chronic conditions (CCC), the authors conducted a cross-sectional survey of primary care providers (N = 132), including physicians, nurse practitioners, and physician assistants, in community settings in 6 counties in northwest North Carolina. Pediatric practices were significantly less likely to be located in rural areas. Practices in rural areas were more likely to be small, with fewer staff members (odds ratio [OR] = 7) and providers (OR = 15) compared with practices in nonrural areas. Additionally, nonrural practices were 3 times as likely as rural practices to have a larger clientele of children with CCC. A majority of primary care providers (77%) reported difficulty caring for children with CCC. Strategies for supporting primary care providers are needed to enable them to provide care for the growing number of children with CCC.

The D&amp;T Report

The D&amp;T Report

Do Telemedicine Wound Care Specialist Consults Meet the Needs of the Referring Physician? A Survey of Primary Care Providers

The purpose of our study was to determine the factors that influence the use of telemedicine consultation by primary care physicians (PCPs) in the management of patients with problem wounds. A short questionnaire was administered to thirty-six PCPs who referred to our Wound Care Program within one year. Participants were asked to rate the importance of specific concerns and benefits regarding the role of wound care surgical specialist (WCSS) and the use of telemedicine consults prior to possible face-to-face consultation. Sixty percent of respondents felt comfortable with telemedicine consultation based on recommendations alone. The total number of patients referred for telemedicine consult was 230, and face-to-face consultation with a WCSS was offered and arranged for 30% of patients. The perception of shared decision making, streamlining patient care, and an opportunity for followup were all highly ranked benefits. The majority of PCPs (93%) agreed that telemedicine wound care consult is a useful tool in their practice and would continue to use the telemedicine consult service.

PS3-14: Primary Care Providers Reported Use of Pre-Screening Discussions for Prostate Cancer Screening: A Cross-Sectional Survey

Background and Aims: There is no scientific consensus for routine prostate cancer screening for men of average risk less than 75 years of age using the prostate-specific antigen test (PSA). However, suggested practice is for physicians to discuss the known harms and potential benefits of PSA testing and digital rectal exam (DRE) with their patients. We conducted a survey of primary care providers (PCPs) to determine their practice styles including discussion regarding prostate cancer screening; we also conducted a patient survey to learn whether their PCPs discussed PSA testing and DRE during a health maintenance exam (HME). Methods: PCPs in the Lovelace Health System were surveyed about their prostate cancer screening practices for average risk men. Based on their responses, they were divided into two groups: routine screeners (RS), those who routinely order PSA testing without discussing potential harms and benefits and informed decision makers (IDM), those who routinely discuss the PSA test and its benefits and harms. After the HME, patients were surveyed as to whether or not their PCP discussed the PSA test and its harms and benefits during their visit. Results: Among the physicians, 35.9% (23/64) were RS and 64.1% (41/64) were IDM. Of the RS patients, 82.3% (51/62) responded that their physician did discuss the PSA test compared to 71.2% (37/52) of the IDM patients (p=0.10). For RS, 58.8% (36/62) of the patients stated their provider initiated the discussion, whereas 56.8% (30/52) of the IDM initiated it. Provider recommendations to have the test were higher for the RS (80.3%) (41/51) compared to 53.1% (20/37) of the IDM p=.0032. Conclusions: By patient report, a higher percentage of RS providers discussed the PSA test with patients. As would be expected, most of the RS recommended the PSA compared to only one-third of the IDM providers. Further studies are needed to determine what other factors of physician practice styles relate to discussing or not discussing prostate cancer screening with patients, and how patient-providers interactions influence screening communication.

Reizdarm: Koloskopieren oder nicht?

Spiegel BMR, Farid M, Esrailian E, Talley J, Chang L. Is irritable bowel syndrome a diagnosis of exclusion? A survey of primary care providers, gastroenterologists, and IBS experts. Am J Gastroenterol 2010; 105: 848 – 858 Chey WD, Nojkov B, Rubenstein JH, Dobhan RR, Greenson JK, Cash BD. The yield of colonoscopy in patients with non-constipated irritable bowel syndrome: results from a prospective, controlled US trial. Am J Gastroenterol 2010; 105: 859 – 865

Is Irritable Bowel Syndrome a Diagnosis of Exclusion? A Survey of Primary Care Providers, Gastroenterologists, and IBS Experts

Guidelines emphasize that irritable bowel syndrome (IBS) is not a diagnosis of exclusion and encourage clinicians to make a positive diagnosis using the Rome criteria alone. Yet many clinicians are concerned about overlooking alternative diagnoses. We measured beliefs about whether IBS is a diagnosis of exclusion, and measured testing proclivity between IBS experts and community providers. We developed a survey to measure decision-making in two standardized patients with Rome III-positive IBS, including IBS with diarrhea (D-IBS) and IBS with constipation (C-IBS). The survey elicited provider knowledge and beliefs about IBS, including testing proclivity and beliefs regarding IBS as a diagnosis of exclusion. We surveyed nurse practitioners, primary care physicians, community gastroenterologists, and IBS experts. Experts were less likely than nonexperts to endorse IBS as a diagnosis of exclusion (8 vs. 72%; P<0.0001). In the D-IBS vignette, experts were more likely to make a positive diagnosis of IBS (67 vs. 38%; P<0.001), to perform fewer tests (2.0 vs. 4.1; P<0.01), and to expend less money on testing (US$297 vs. $658; P<0.01). Providers who believed IBS is a diagnosis of exclusion ordered 1.6 more tests and consumed $364 more than others (P<0.0001). Experts only rated celiac sprue screening and complete blood count as appropriate in D-IBS; nonexperts rated most tests as appropriate. Parallel results were found in the C-IBS vignette. Most community providers believe IBS is a diagnosis of exclusion; this belief is associated with increased resource use. Experts comply more closely with guidelines to diagnose IBS with minimal testing. This disconnect suggests that better implementation of guidelines is warranted to minimize variation and improve cost-effectiveness of care.

Patient selection and provision of the intrauterine device: a survey of primary care providers

Patient selection and provision of the intrauterine device: a survey of primary care providers

Child Overweight Interventions in Rural Primary Care Practice: A Survey of Primary Care Providers in Southern Appalachia

Child overweight has reached an epidemic level throughout the United States. A total of 65 primary care providers in southern Appalachia were surveyed to understand current issues in addressing child overweight in rural primary care practice. The study shows that while providers realized the importance of child overweight intervention, many were not ready and did little to address child overweight in their practices. The providers' skill levels in addressing child overweight were generally less than sufficient. Common barriers to child overweight treatment included lack of parental motivation and involvement, lack of supportive services, and lack of clinician time. In conclusion, rural primary care is facing many challenges in addressing child overweight. However, with more training in behavioral intervention skills and through establishing a family-based intervention and a group visit approach, primary care providers could play a more active role in the fight against the epidemic of child overweight.

The frequency of missed test results and associated treatment delays in a highly computerized health system

Background:Diagnostic errors associated with the failure to follow up on abnormal diagnostic studies ("missed results") are a potential cause of treatment delay and a threat to patient safety. Few data exist concerning the frequency of missed results and associated treatment delays within the Veterans Health Administration (VA).Objective:The primary objective of the current study was to assess the frequency of missed results and resulting treatment delays encountered by primary care providers in VA clinics.Methods:An anonymous on-line survey of primary care providers was conducted as part of the health systems ongoing quality improvement programs. We collected information from providers concerning their clinical effort (e.g., number of clinic sessions, number of patient visits per session), number of patients with missed abnormal test results, and the number and types of treatment delays providers encountered during the two week period prior to administration of our survey.Results:The survey was completed by 106 out of 198 providers (54 percent response rate). Respondents saw and average of 86 patients per 2 week period. Providers encountered 64 patients with missed results during the two week period leading up to the study and 52 patients with treatment delays. The most common missed results included imaging studies (29 percent), clinical laboratory (22 percent), anatomic pathology (9 percent), and other (40 percent). The most common diagnostic delays were cancer (34 percent), endocrine problems (26 percent), cardiac problems (16 percent), and others (24 percent).Conclusion:Missed results leading to clinically important treatment delays are an important and likely underappreciated source of diagnostic error.