James M. Gill

Defining and measuring the patient-centered medical home

AbstractThe patient-centered medical home (PCMH) is four things: 1) the fundamental tenets of primary care: first contact access, comprehensiveness, integration/coordination, and relationships involving sustained partnership; 2) new ways of organizing practice; 3) development of practices’ internal capabilities, and 4) related health care system and reimbursement changes. All of these are focused on improving the health of whole people, families, communities and populations, and on increasing the value of healthcare.The value of the fundamental tenets of primary care is well established. This value includes higher health care quality, better whole-person and population health, lower cost and reduced inequalities compared to healthcare systems not based on primary care.The needed practice organizational and health care system change aspects of the PCMH are still evolving in highly related ways. The PCMH will continue to evolve as evidence comes in from hundreds of demonstrations and experiments ongoing around the country, and as the local and larger healthcare systems change. Measuring the PCMH involves the following:Giving primacy to the core tenets of primary careAssessing practice and system changes that are hypothesized to provide added valueAssessing development of practices’ core processes and adaptive reserveAssessing integration with more functional healthcare system and community resourcesEvaluating the potential for unintended negative consequences from valuing the more easily measured instrumental features of the PCMH over the fundamental relationship and whole system aspectsRecognizing that since a fundamental benefit of primary care is its adaptability to diverse people, populations and systems, functional PCMHs will look different in different settings.Efforts to transform practice to patient-centered medical homes must recognize, assess and value the fundamental features of primary care that provide personalized, equitable health care and foster individual and population health.

Prospects For Rebuilding Primary Care Using The Patient-Centered Medical Home

Existing research suggests that models of enhanced primary care lead to health care systems with better performance. What the research does not show is whether such an approach is feasible or likely to be effective within the U.S. health care system. Many commentators have adopted the model of the patient-centered medical home as policy shorthand to address the reinvention of primary care in the United States. We analyze potential barriers to implementing the medical home model for policy makers and practitioners. Among others, these include developing new payment models, as well as the need for up-front funding to assemble the personnel and infrastructure required by an enhanced non-visit-based primary care practice and methods to facilitate transformation of existing practices to functioning medical homes.

Relationship between continuity of care and diabetes control: Evidence from the Third National Health and Nutrition Examination Survey

OBJECTIVES We examined the relationship between continuity of care and diabetes control. METHODS We analyzed data on 1400 adults with diabetes who took part in the Third National Health and Nutrition Examination Survey. We examined the relationship of continuity of care with glycemic, blood pressure, and lipid control. RESULTS Continuity of care was associated with both acceptable and optimal levels of glycemic control. Continuity was not associated with blood pressure or lipid control. There was no difference between having a usual site but no usual provider and having a usual provider in any of the investigated outcomes. CONCLUSIONS Continuity of care is associated with better glycemic control among people with diabetes. Our results do not support a benefit of having a usual provider above having a usual site of care.

Impact of Provider Continuity on Quality of Care for Persons With Diabetes Mellitus

BACKGROUND Many patients with diabetes fail to receive recommended monitoring tests. One reason might be inadequate continuity of care. This study examined the association between provider continuity and completion of monitoring tests for patients with diabetes mellitus. METHODS A cross-sectional analysis was conducted on claims data from a private national health plan for 1 year (January 1,1999, through December 31,1999). Participants had a diagnosis of diabetes mellitus and at least 2 outpatient visits during the study year (N = 1,795). The association was measured between continuity of care with an individual provider and completion of 3 diabetes monitoring tests: a glycosylated hemoglobin test, a lipid profile, and an eye examination. RESULTS Eighty-one percent of patients had a glycosylated hemoglobin test, 66% had a lipid profile, and 28% had an eye examination during the study year. After controlling for demographics, number of diabetes visits, case mix, and diabetes complications, provider continuity was not significantly associated with the receipt of a glycosylated hemoglobin test (odds ratio [OR] = 0.61, 95% confidence interval [CI], 0.32-1.16), a lipid profile (OR = 0.97, 95% CI, 0.57-1.64) or an eye examination (OR = 0.60, 95% CI, 0.30-1.19). When continuity was measured only among primary care providers, there was no significant association for receipt of a glycosylated hemoglobin test (OR = 0.73, 95% CI, 0.41-1.33), a lipid profile (OR = 0.88, 95% CI, 0.53-1.47) or an eye examination (OR = 0.70, 95% CI, 0.35-1.36). CONCLUSIONS This study found no association between provider continuity and completion of diabetes monitoring tests in a national privately insured population. Whereas continuity might benefit other aspects of health care, it does not appear to benefit improved monitoring for diabetes.

Management of venous thromboembolism: a clinical practice guideline from the American College of Physicians and the American Academy of Family Physicians.

Venous thromboembolism is a common condition affecting 7.1 persons per 10,000 person-years among community residents. Incidence rates for venous thromboembolism are higher in men, African-Americans, and increase substantially with age. It is critical to treat deep venous thrombosis at an early stage to avoid development of further complications, such as pulmonary embolism or recurrent deep venous thrombosis. The target audience for this guideline is all clinicians caring for patients who have been given a diagnosis of deep venous thrombosis or pulmonary embolism. The target patient population is patients receiving a diagnosis of pulmonary embolism or lower-extremity deep venous thrombosis.

Elevated Serum Transferrin Saturation and Mortality

BACKGROUND A large proportion of US adults have elevated transferrin saturation, an indicator of a predisposition for iron overload. The purpose of this study was to evaluate the relationship between elevated serum transferrin saturation and mortality. METHODS This cohort study was conducted using data from the First Health and Nutrition Examination Survey I (1971–1974) (NHANES I) merged with the NHANES I Epidemiologic Followup Study (1992) (N = 10,714). We used SUDAAN and appropriate weights to make population estimates for the adult US population (aged 25 to 74 years at baseline). All-cause mortality was evaluated in relation to serum transferrin saturation of greater than 45%, greater than 50%, greater than 55%, and greater than 60% using Cox proportional hazards regression. RESULTS In a Cox proportional hazards model controlling for potential confounders, including comorbid diseases, smoking, and cholesterol, all-cause mortality is significantly greater for persons with a serum transferrin saturation of more than 55%, compared with those with saturations below this cutoff (hazards ratio [HR] =1.60, 95% confidence interval [CI], 1.17–2.21). No one who died had hemochromatosis as any of the 20 listed causes of death. Many of the underlying causes of death for persons with serum transferrin saturation levels of more than 55% are common causes of death in the general population, although these persons were more likely to have died of cirrhosis and diabetes, a finding consistent with iron overload. CONCLUSIONS In this nationally representative cohort of adults, those with elevated serum transferrin saturation, more than 2% of the adult US population, were at increased risk for all-cause mortality.

Transferrin Saturation, Dietary Iron Intake, and Risk of Cancer

PURPOSE Transferrin saturation of more than 60% has been identified as a cancer risk factor. It is unclear whether dietary iron intake increases the risk of cancer among individuals with transferrin saturation of less than 60%. The purpose of this study was to examine the association of dietary iron intake and the risk of cancer among adults with increased transferrin saturation. METHODS Analysis of a cohort study, the National Health and Nutrition Examination Survey I Epidemiologic Follow-Up Study, was performed. US adults (aged 25 to 74 years at baseline) were followed up from baseline in 1971–1974 to 1992 (N = 6,309). RESULTS A total of 7.3% of the US population had a serum transferrin saturation of more than 45% at baseline. Intake of dietary iron was essentially uncorrelated with transferrin saturation (r = 0.04). Compared with individuals who had normal serum transferrin saturation and low dietary iron intake, individuals whose serum transferrin saturation was more than 45% and who had high dietary iron intake also had an increased adjusted relative risk of cancer (2.24; 95% confidence interval [CI], 1.02-4.89). Increased risk was not found for individuals with a transferrin saturation of more than 45% but a normal dietary iron intake (hazard ratio, 1.02; 95% CI, 0.69–1.49). Transferrin saturation levels could be set as low as 41%, and the individuals with high transferrin saturation and high dietary iron intake would still have an increased adjusted relative risk of cancer (hazard ratio, 2.00; 95% CI, 1.04–3.82). CONCLUSIONS Among persons with increased transferrin saturation, a daily intake of dietary iron more than 18 mg is associated with an increased risk of cancer. Future research might focus on the benefits of dietary changes in those individuals with increased serum transferrin saturation.

Perception, Intention, and Action in Adolescent Obesity

Background: Insight into adolescents’ weight-loss behavior is needed. Methods: Survey data were obtained from overweight and obese adolescents in the Youth Risk Behavioral Survey (YRBS) in Delaware. Cross tabulations were used to determine the frequency of accurate perception, recent action, and current intention regarding weight loss. Multivariable analysis identified factors associated with recent action to lose weight. Results: From 2728 records, 482 overweight adolescents and 398 obese adolescents were identified. Most obese (83%) and overweight (79%) adolescents reported recent action to lose weight. Most obese (75%) and overweight (65%) adolescents intended to lose weight. Obese and overweight adolescents who reported a current intention to lose weight were more likely to have taken recent action to lose weight (odds ratio [OR], 11.6 and 6.6, respectively). Conclusions: The percentage of obese and overweight adolescents who have an accurate perception of weight, intend to lose weight, and have taken recent action to lose weight suggests that this group is highly engaged in weight-related behavior change. Compared with their obese peers, overweight adolescents seem less engaged in weight change behavior. There is a strong association in both groups between intention and recent action, and this association indicates that obese and overweight adolescents are highly motivated to change their weight.

Accuracy of screening for diabetic retinopathy by family physicians.

BACKGROUND We wanted to examine the accuracy of family physicians’ screening for diabetic retinopathy using standardized criteria and a nonmydriatic ophthalmoscope. METHODS Eleven family physicians assessed 28 standardized patients with diabetes mellitus using the PanOptic ophthalmoscope. Their assessments of whether the patients required referral to an ophthalmologist were compared with the reference standard of retinal diagrams. RESULTS The mean sensitivity for the family physicians was 87% (95% confidence interval [CI], 83%–91%) with a specificity of 57% (95% CI, 46%–68%). Overall agreement was moderate, with a mean κ = .43 (95% CI, 0.39%–0.47%). CONCLUSIONS Using standardized criteria and a nonmydriatic ophthalmoscope, family physicians were fairly accurate in screening patients for diabetic retinopathy. Whereas this technique is not sufficiently accurate to replace routine referral for all patients with diabetes, it can be used to improve care for those patients who fail to get routine eye screenings.

Antidepressant Medication Use for Primary Care Patients with and without Medical Comorbidities: A National Electronic Health Record (EHR) Network Study

Background: Because comorbid depression can complicate medical conditions (eg, diabetes), physicians may treat depression more aggressively in patients who have these conditions. This study examined whether primary care physicians prescribe antidepressant medications more often and in higher doses for persons with medical comorbidities. Methods: This secondary data analysis of electronic health record data was conducted in the Centricity Health Care User Research Network (CHURN), a national network of ambulatory practices that use a common outpatient electronic health record. Participants included 209 family medicine and general internal medicine providers in 40 primary care CHURN offices in 17 US states. Patients included adults with a new episode of depression that had been diagnosed during the period October 2006 through July 2007 (n = 1513). Prescription of antidepressant medication and doses of antidepressant medication were compared for patients with and without 6 comorbid conditions: diabetes, coronary heart disease, congestive heart failure, cerebrovascular disease, chronic obstructive pulmonary disease, and cancer. Results: 20.7% of patients had at least one medical comorbidity whereas 5.8% had multiple comorbidities. Overall, 77% of depressed patients were prescribed antidepressant medication. After controlling for age and sex, patients with multiple comorbidities were less likely to be prescribed medication (adjusted odds ratio, 0.58; 95% CI, 0.35–0.96), but there was no significant difference by individual comorbidities. Patients with cerebrovascular disease were less likely to be prescribed a full dose of medication (adjusted odds ratio, 0.26; 95% CI, 0.08–0.88), but there were no differences for other comorbidities or for multiple comorbidities, and there was no difference for any comorbidities in the prescription of minimally effective doses. Conclusions: Patients with new episodes of depression who present to a primary care practice are not treated more aggressively if they have medical comorbidities. In fact, patients with multiple comorbidities are treated somewhat less aggressively.