Karen Davis

A 2020 Vision of Patient-Centered Primary Care

Patient-centered care has received new prominence with its inclusion by the Institute of Medicine as 1 of the 6 aims of quality. Seven attributes of patient-centered primary care are proposed here to improve this dimension of care: access to care, patient engagement in care, information systems, care coordination, integrated and comprehensive team care, patient-centered care surveys, and publicly available information. The Commonwealth Fund 2003 National Survey of Physicians and Quality of Care finds that one fourth of primary care physicians currently incorporate these various patient-centered attributes in their practices. To bring about marked improvement will require a new system of primary care payment that blends monthly patient panel fees with traditional fee-for-service payment, and new incentives for patient-centered care performance. A major effort to test this concept, develop a business case, provide technical assistance and training, and diffuse best practices is needed to transform American health care.

SYSTEMIC ALPHA-ADRENERGIC BLOCKADE WITH PHENTOLAMINE : A DIAGNOSTIC TEST FOR SYMPATHETICALLY MAINTAINED PAIN

The diagnosis of sympathetically maintained pain (SMP) is typically established by assessment of pain relief during local anesthetic blockade of the sympathetic ganglia that innervate the painful body part. To determine if systemic alpha-adrenergic blockade with phentolamine can be used to diagnose SMP, we compared the effects on pain of local anesthetic sympathetic ganglion blocks (LASB) and phentolamine blocks (PhB) in 20 patients with chronic pain and hyperalgesia that were suspected to be sympathetically maintained. The blocks were done in random order on separate days. Patients rated the intensity of ongoing and stimulus-evoked pain every 5 min before, during, and after the LASB and PhB. Patients and the investigator assessing pain levels were blinded to the time of intravenous administration of phentolamine (total dose 25-35 mg). The pain relief achieved by LASB and PhB correlated closely (r = 0.84), and there was no significant difference in the maximum pain relief achieved with the two blocks (t = 0.19, P greater than 0.8). Nine patients experienced a greater than 50% relief of pain and hyperalgesia from both LASB and PhB and were considered to have a clinically significant component of SMP. We conclude that alpha-adrenergic blockade with intravenous phentolamine is a sensitive alternative test to identify patients with SMP.

Continuous Innovation In Health Care: Implications Of The Geisinger Experience

To achieve the diverse health care goals of the United States, health care value must increase. The capacity to create value through innovation is facilitated by an integrated delivery system focused on creating value, measuring innovation returns, and receiving market rewards. This paper describes the Geisinger Health Systems innovation strategy for care model redesign. Geisingers clinical leadership, dedicated innovation team, electronic health information systems, and financial incentive alignment each contribute to its innovation record. Although Geisingers characteristics raise serious questions about broad applicability to nonintegrated health care organizations, its experience can provide useful insights for health system reform.

Altered central somatosensory processing in chronic pain patients with “hysterical” anesthesia

Objective: The authors hypothesized that central factors may underlie sensory deficits in patients with nondermatomal somatosensory deficits (NDSD) and that functional brain imaging would reveal altered responses in supraspinal nuclei. Background: Patients with chronic pain frequently present with NDSD, ranging from hypoesthesia to complete anesthesia in the absence of substantial pathology and often in association with motor weakness and occasional paralysis. Patients with pain and such pseudoneurologic symptoms can be classified as having both a pain disorder and a conversion disorder (Diagnostic and Statistical Manual of Mental Disorders–IV classification). Methods: The authors tested their hypothesis with functional MRI (fMRI) of brush and noxious stimulation-evoked brain responses in four patients with chronic pain and NDSD. Results: The fMRI findings revealed altered somatosensory-evoked responses in specific forebrain areas. Unperceived stimuli failed to activate areas that were activated with perceived touch and pain: notably, the thalamus, posterior region of the anterior cingulate cortex (ACC), and Brodmann area 44/45. Furthermore, unperceived stimuli were associated with deactivations in primary and secondary somatosensory cortex (S1, S2), posterior parietal cortex, and prefrontal cortex. Finally, unperceived (but not perceived) stimuli activated the rostral ACC. Conclusions: Diminished perception of innocuous and noxious stimuli is associated with altered activity in many parts of the somatosensory pathway or other supraspinal areas. The cortical findings indicate a neurobiological component for at least part of the symptoms in patients presenting with nondermatomal somatosensory deficits.

CORTICAL THINNING IN IBS: IMPLICATIONS FOR HOMEOSTATIC, ATTENTION, AND PAIN PROCESSING

Chronic pain may be accompanied by abnormal functioning in pain, attention, or homeostatic systems. We recently identified abnormal rectal-evoked functional MRI responses in patients with irritable bowel syndrome (IBS) in brain regions associated with such systems, including the insula and anterior cingulate cortex (ACC).1 However, it is not known whether structural brain abnormalities contribute to these responses. We tested the hypothesis that abnormal cortical responses in IBS are at least partly due to structural differences within the insula and ACC. ### Methods. Right-handed healthy control subjects (n = 11, 7 women, 4 men; 24 to 50 years old) and patients with IBS (n = 9, 6 women, 3 men; 30 to 58 years old) provided written consent to procedures approved by the University Health Network Research Ethics Board. Control subjects were excluded if they had a history of bowel disorders, chronic pain, fibromyalgia, diabetes, or psychiatric illness. Patients were recruited from the Toronto Western Hospital Gastrointestinal Unit, met Rome III criteria2 for diagnosis of IBS, and had mild to moderate symptoms and pain for more than 2 years. Exclusion criteria were a history of …

Uninsured and underserved: inequities in health care in the United States.

quality and most sophisticated systems of medical care in the world. Most Americans take for granted their access to this system of care. In times of emergency or illness, they can call upon a vast array of health resources-from a family physician to a complex teaching hospital-assured that they will receive needed care and that their health insurance coverage will pick up the tab for the majority of bills incurred.

Abnormal forebrain activity in functional bowel disorder patients with chronic pain.

Background: Abnormal cortical pain responses in patients with fibromyalgia and conversion disorder raise the possibility of a neurobiologic basis underlying so-called “functional” chronic pain. Objective: To use percept-related fMRI to test the hypothesis that patients with a painful functional bowel disorder do not process visceral input or sensations normally or effectively at the cortical level. Methods: Eleven healthy subjects and nine patients with irritable bowel syndrome (IBS) underwent fMRI during rectal distensions that elicited either a moderate level of urge to defecate or pain. Subjects continuously rated their rectal stimulus–evoked urge or pain sensations during fMRI acquisition. fMRI data were interrogated for activity related to stimulus presence and to specific sensations. Results: In IBS, abnormal responses associated with rectal-evoked sensations were identified in five brain regions. In primary sensory cortex, there were urge-related responses in the IBS but not control group. In the medial thalamus and hippocampus, there were pain-related responses in the IBS but not control group. However, pronounced urge- and pain-related activations were present in the right anterior insula and the right anterior cingulate cortex in the control group but not the IBS group. Conclusions: Percept-related fMRI revealed abnormal urge- and pain-related forebrain activity during rectal distension in patients with irritable bowel syndrome (IBS). As visceral stimulation evokes pain and triggers unconscious processes related to homeostasis and reflexes, abnormal brain responses in IBS may reflect the sensory symptoms of rectal pain and hypersensitivity, visceromotor dysfunction, and abnormal interoceptive processing.

How the Affordable Care Act Will Strengthen the Nation's Primary Care Foundation

As the country turns toward implementation of the Patient Protection and Affordable Care Act, realizing the potential of reform will require significant transformation of the American system of health care delivery. To that end, the new law seeks to strengthen the nation’s primary care foundation through enhanced reimbursement rates for providers and the use of innovative delivery models such as patient-centered medical homes. Evidence suggests that these strategies can return substantial benefits to both patients and providers by increasing access to primary care services, reducing administrative hassles and burdens, and facilitating coordination across the continuum of care. If successfully implemented, the Affordable Care Act has the potential to realign incentives within the health system and create opportunities for providers to be rewarded for delivering high value, patient-centered primary care. Such a transformation could lead to better outcomes for patients, increase job satisfaction among physicians and encourage more sustainable levels of health spending for the nation.

Cognitive and default-mode resting state networks: Do male and female brains “rest” differently?

Variability in human behavior related to sex is supported by neuroimaging studies showing differences in brain activation patterns during cognitive task performance. An emerging field is examining the human connectome, including networks of brain regions that are not only temporally‐correlated during different task conditions, but also networks that show highly correlated spontaneous activity during a task‐free state. Both task‐related and task‐free network activity has been associated with individual task performance and behavior under certain conditions. Therefore, our aim was to determine whether sex differences exist during a task‐free resting state for two networks associated with cognitive task performance (executive control network (ECN), salience network (SN)) and the default mode network (DMN). Forty‐nine healthy subjects (26 females, 23 males) underwent a 5‐min task‐free fMRI scan in a 3T MRI. An independent components analysis (ICA) was performed to identify the best‐fit IC for each network based on specific spatial nodes defined in previous studies. To determine the consistency of these networks across subjects we performed self‐organizing group‐level ICA analyses. There were no significant differences between sexes in the functional connectivity of the brain areas within the ECN, SN, or the DMN. These important findings highlight the robustness of intrinsic connectivity of these resting state networks and their similarity between sexes. Furthermore, our findings suggest that resting state fMRI studies do not need to be controlled for sex. Hum Brain Mapp, 2010.

Health information technology and physician perceptions of quality of care and satisfaction

OBJECTIVE To examine across seven countries the relationship between physician office information system capacity and the quality of care. DESIGN Multivariate analysis of a cross-sectional 2006 random survey of primary care physicians in seven countries: Australia, Canada, Germany, the Netherlands, New Zealand, United Kingdom, and United States. MAIN OUTCOME MEASURES coordination and safety of care, care for chronically ill patients, and satisfaction with practice of medicine. RESULTS The study finds significant disparities in the quality of health care between practices with low information system capacity and those with high technical capacity after controlling for within country differences and practice size. There were significant physician satisfaction differences with the overall experience of practicing medicine by information system level. CONCLUSIONS For policy leaders, the seven-nation survey suggests that health systems that promote information system infrastructure are better able to address coordination and safety issues, particularly for patients with multiple chronic conditions, as well as to maintain primary care physician workforce satisfaction.