Thomas C. Rosenthal

The Medical Home: Growing Evidence to Support a New Approach to Primary Care

Introduction: A medical home is a patient-centered, multifaceted source of personal primary health care. It is based on a relationship between the patient and physician, formed to improve the patients health across a continuum of referrals and services. Primary care organizations, including the American Board of Family Medicine, have promoted the concept as an answer to government agencies seeking political solutions that make quality health care affordable and accessible to all Americans. Methods: Standard literature databases, including PubMed, and Internet sites of numerous professional associations, government agencies, business groups, and private health organizations identified over 200 references, reports, and books evaluating the medical home and patient-centered primary care. Findings: Evaluations of several patient-centered medical home models corroborate earlier findings of improved outcomes and satisfaction. The peer-reviewed literature documents improved quality, reduced errors, and increased satisfaction when patients identify with a primary care medical home. Patient autonomy and choice also contributes to satisfaction. Although industry has funded case management models demonstrating value superior to traditional fee-for-service reimbursement adoption of the medical home as a basis for medical care in the United States, delivery will require effort on the part of providers and incentives to support activities outside of the traditional face-to-face office visit. Conclusions: Evidence from multiple settings and several countries supports the ability of medical homes to advance societal health. A combination of fee-for-service, case management fees, and quality outcome incentives effectively drive higher standards in patient experience and outcomes. Community/provider boards may be required to safeguard the public interest.

HIV/AIDS in the Rural United States: Epidemiology and Health Services Delivery

This integrated research review addresses the epidemiology of rural human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) and the organization, financing, and delivery of health services for rural persons living with HIV or AIDS (PLWHIVs, PLWAs). Several abstracting services, indexing services, and bibliographies were searched. An annotation form served as the guideline for data extraction. Several conclusions emerged from this review. Epidemiological evidence indicates that there has been a dramatic increase in the relative proportion of rural HIV/AIDS incident cases over the past 5 years. Explanations for the rural increase focus on injection drug use, heterosexual behavior, and sexually transmitted disease levels. Dramatically elevated rates of infection in rural Black women are indicated. Rural areas experience important levels of in-migration of HIV/AIDS-infected individuals. The health services literature suggests that rural providers and institutions have limited resources and little experience with PLWHIVs or PLWAs.

The Adoption and Use of Health Information Technology in Rural Areas: Results of a National Survey

CONTEXT Health information technology (HIT) is a national policy priority. Knowledge about the special needs, if any, of rural health care providers should be taken into account as policy is put into action. Little is known, however, about rural-urban differences in HIT adoption at the national level. PURPOSE To conduct the first national assessment of HIT in rural primary care offices, with particular attention to electronic medical record (EMR) adoption, range of capabilities in use, and plans for adoption. METHODS A national mail survey of 5,200 primary care offices, stratified by rurality using Rural-Urban Commuting Area categories, was conducted in 2007-2008. Regression analyses were used to assess the relationship between office characteristics and EMR adoption, capabilities used, and future adoption plans. RESULTS A commercial EMR system was present in 31% of offices, with no significant differences by rurality. Of offices with EMRs, 12% reported using a full range of EMR capabilities, with 51% using a basic range and 37% using less than the basic range. Large Rural (adjusted OR = 3.71, P= .022) and Small Rural (aOR = 3.75, P= .049) offices were more likely than Urban offices to use a broader range of EMR capabilities. Among offices without EMRs, those in Isolated areas were less likely to have more immediate plans to adopt (aOR = 0.19, P= .02). CONCLUSIONS HIT adoption and use in rural primary care offices does not appear to be lower than in urban offices. The situation, however, is dynamic and warrants further monitoring.

Factors in the physician practice location puzzle: a survey of New York State residency-trained family physicians.

Background: For the past 5 years fewer medical students have selected primary care specialties, and one-third of all physicians have indicated they will move in the next 5 years. These two factors make family physicians one of the most recruited specialties in medicine. Methods: A questionnaire about practice profiles and factors that have an impact on a physician’s location decision was mailed to all physicians who graduated from New York State family medicine residencies between 1970 and 1989. Data from completed responses were analyzed by year of graduation from residency, community size, and whether the responder remained in New York State or chose to locate outside New York State. Results: There were 711 (46 percent) physicians who responded. The number of minorities remained stable at 14 percent during these years, but women graduates increased from 12 percent to 21 percent. The graduates in the 1980s, when compared with those in the 1970s, were more likely to be salaried, make less money, and to believe employment for the physician’s spouse to be important in practice location. The 38 percent of responders from communities of fewer than 25,000 were less likely to be salaried, were more likely to practice in a group, worked more hours, offered a broader range of services including obstetrics, made less money, and placed less importance on availability of hospital consultants. Extended family, previous negotiated obligations, and geographic or climate issues were the reasons 64 percent of out-of-state responders gave for leaving New York. Spouse’s opinion, hospital consultants, hospital services, colleague interaction, and after-hours coverage were most frequently rated as important factors for family physician practice location. Conclusions: Factors important in attracting new physicians to a community include the spouse’s opinion, institutional and colleague support, and lifestyle issues.

Building Learning Practices with Self-Empowered Teams for Improving Patient Safety

BACKGROUND AND OBJECTIVES: Each primary care practice should be viewed as a complex adaptive micro-system with its own unique characteristics. To improve safety, under constraints of limited resources and numerous competing demands, practices need to identify those vulnerabilities that pose the greatest risks and focus efforts on these. The Objective was to develop and test a novel methodology that forms self-empowered learning teams that can prioritise safety problems based on the combination of error frequency and severity of consequences, and then devise feasible interventions. METHODS: A survey instrument was designed and used to elicit, in qualitative terms, staff perceptions of frequency, p, and severity, s, of various types/causes of primary care errors. The qualitative responses were quantified using an algorithm that allowed for risk aversion. Relative hazard rate, h = pxs, was used as the basis for prioritising safety problems in two primary care test practices. RESULTS: Each site identified its own set of priorities with very little overlap. Within each site there was high concordance between priorities identified by physicians, nursing and administrative staff but each site appeared to be unique. Priorities also remained stable with variation in the degree of risk aversiveness assumed in the Hazard calculation. INTERPRETATION AND CONCLUSIONS: The method aided formation of central ‘attractors’ in the form of self-empowered effective learning teams with a common vision to help their complex micro-systems to adapt and thrive. This pro-active type of methodology helps in creating a sustainable safety culture, and has been adapted for other health-care settings and physician training.

Curricula for teaching the content of clinical practice guidelines to family medicine and internal medicine residents in the US: a survey study

BackgroundTeaching the content of clinical practice guidelines (CPGs) is important to both clinical care and graduate medical education. The objective of this study was to determine the characteristics of curricula for teaching the content of CPGs in family medicine and internal medicine residency programs in the United States.MethodsWe surveyed the directors of family medicine and internal medicine residency programs in the United States. The questionnaire included questions about the characteristics of the teaching of CPGs: goals and objectives, educational activities, evaluation, aspects of CPGs that the program teaches, the methods of making texts of CPGs available to residents, and the major barriers to teaching CPGs.ResultsOf 434 programs responding (out of 839, 52%), 14% percent reported having written goals and objectives related to teaching CPGs. The most frequently taught aspect was the content of specific CPGs (76%). The top two educational strategies used were didactic sessions (76%) and journal clubs (64%). Auditing for adherence by residents was the primary evaluation strategy (44%), although 36% of program directors conducted no evaluation. Programs made texts of CPGs available to residents most commonly in the form of paper copies (54%) while the most important barrier was time constraints on faculty (56%).ConclusionResidency programs teach different aspects of CPGs to varying degrees, and the majority uses educational strategies not supported by research evidence.

Experience with community academic practice: Strategies for the ambulatory education of residents

The expectation that training programs will place more of their physician graduates into primary care has caused internal medicine programs to explore different educational experiences for their residents. One proposal is to transfer the ambulatory training site for residents from the hospital clinic to a community academic practice (CAP) site. We discuss the theoretical aspects, the practical considerations, and our experience with one CAP site, including the problems that have been solved and the problems remaining.

Cardiovascular Risk Factor Status Of An Old Order Mennonite Community

Background: The Old Order Mennonites are members of rural farming communities whose religious and cultural traditions pervade their dietary and health practices. These cloistered Christian communities often present special challenges to primary care physicians unfamiliar with the Mennonite way of life. Anecdotal descriptions of Mennonite customs suggest heightened risk for cardiovascular disease because of a dairy and meat-based diet and a lack of utilization of the traditional health care system. Methods: With approval from the church bishop, households from a New York State Mennonite community were interviewed about personal and family history of cardiovascular disease, knowledge of dietary cardiovascular risk factors, and personal awareness of their cardiovascular risk factor status. A standardized Saturated Fat/Cholesterol Avoidance Scale was used to assess qualitatively the community’s traditional diet. Blood pressures and total serum cholesterol levels were measured in all willing participants. Results: Two hundred fifty interviews were completed. A significant difference was found between the cholesterol level of the men (181 mg/dL) and the women (192 mg/dL). When compared with the general population, the Mennonite men had significantly lower total serum cholesterol levels and systolic and diastolic blood pressures. Only 8 percent of the study population had been previously screened for serum cholesterol. One-third of the population older than 55 years had a personal history of either myocardial infarction or stroke. The study population’s score on the Saturated Fat/Cholesterol Avoidance Scale indicated a diet higher in saturated fat and cholesterol than that of other study populations. Conclusions: Our findings indicate a significant lack of preventive health care practices, minimal avoidance of dietary cardiovascular risk factors, and a significant difference between men’s and women’s cardiovascular risk factor status in this Old Order Mennonite population.

Are We Learning More about Patient-centered Medical Homes (PCMHs), or Learning More about Primary Care?

The 1971 report by Millis[1][1] promoted family medicine as the remedy for an American health care system “designed to cure the acutely ill and available to those who could afford to pay.” More than 40 years later, the annual premium for family health coverage has risen to 34% of the average