scholarly journals Panel Size, Office Visits, and Care Coordination Events: A New Workload Estimation Methodology Based on Patient Longitudinal Event Histories

2018 ◽  
Vol 3 (2) ◽  
pp. 238146831878718 ◽  
Author(s):  
Michael C. Rossi ◽  
Hari Balasubramanian
Keyword(s):  
Primary Care ◽  
Emergency Room ◽  
Office Visit ◽  
Medical Expenditure ◽  
Hospital Inpatient ◽  
Office Visits ◽  
Panel Size ◽  
Face To Face ◽  
Number Of Patients ◽  
Event Histories

Background. Panel size, or the number of patients a primary care physician (PCP) and her care team can feasibly manage as part of a practice, remains a vital question in primary care. Objective. To Illustrate a new methodology for quantifying two types of workload associated with a panel size: 1) the PCP weekly office visit distribution and 2) the weekly distribution of non-PCP events (subspecialty visits, emergency room visits, hospitalizations) that potentially require non–face-to-face coordination. Methods. We assemble granular individual-level histories of events in the health system using the Medical Expenditure Panel Survey from 2011. Using the date on which each event occurred, we create weekly utilization estimates as a function of panel size for the general population and Medicare patients. Results. A PCP with a panel of 2,000 adults approximately representative of the US population can expect to have 93.54 office visits on average each week. A simple model quantifying demand–capacity mismatch suggests that a PCP with a weekly capacity of 80 to 90 appointments will struggle to satisfy this office-visit demand in a timely manner. Furthermore, each week the PCP can expect the same panel to have 9.08 visits to the emergency room, 4.69 hospital inpatient events, and 131.29 office-based visits to non–primary care subspecialists; these events contribute to the non–face-to-face coordination workload, increasing the probability of an overburdened workweek. Both PCP office visit and coordination events are highly concentrated in less than 200 individuals (<10% of the 2,000). Conclusion. Patient-level longitudinal event histories can be retrospectively assembled to quantify patterns of face-to-face office visits and coordination workload associated with a primary care panel.

scholarly journals Implementation of Targeted Screening for Poverty in a Large Primary Care Team in Toronto, Canada: a feasibility study

2021 ◽  
Author(s):  
Kimberly Wintemute ◽  
Meh Noor ◽  
Aashka Bhatt ◽  
Gary Bloch ◽  
Suja Arackal ◽  
...  
Keyword(s):  
Primary Care ◽  
Screening Program ◽  
Office Visit ◽  
Care Team ◽  
Primary Care Team ◽  
Community Based ◽  
Implementation Evaluation ◽  
Number Of Patients ◽  
Targeted Screening ◽  
Deprived Areas

Abstract Background Poverty has a significant influence on health. Efforts to optimize income and reduce poverty could make a difference to the lives of patients and their families. Routine screening for poverty in primary care is an important first step but rarely occurs in Canada. We aimed to implement a targeted screening and referral process in a large, distributed primary care team in Toronto, Ontario, Canada.Methods This implementation evaluation was conducted with a large community-based primary care team in north Toronto. The primary care team serves relatively wealthy neighborhoods that contain pockets of poverty. Physicians were invited to participate. We implemented targeted screening by combining census information on neighborhood-level deprivation with postal codes in patient records. For physicians agreeing to participate, we added prompts to screen for poverty to the charts of adult patients living in the most deprived areas. Standardized electronic medical record templates recommended a referral to a team case worker for income optimization, for those patients screening positive. We recorded the number and percentages of participants at each stage, from screening to receiving advice on income optimization. Results The primary care team included 86 physicians distributed across 19 clinical locations. Thirty-four physicians (39%) participated. Their practices provided care for 27,290 patients aged 18 or older; 852 patients (3%) were found to be living in the most deprived neighborhoods. 509 (60%) had at least one office visit over the 6 months of follow up, and 128 (25%) of those seen were screened. Only 25 (20%) of these patients screened positive for poverty, and 13 (52%) were referred. Eight patients (62% of those referred) were ultimately seen by a caseworker for income optimization.Discussion & Conclusions We implemented a targeted poverty screening program combined with resources to optimize income for patients in a large, distributed community-based primary care team. However, only a small number of patients were identified and linked to the intervention Further efforts to scale and spread screening and mitigation of poverty are warranted; these should include broadening the targeted population beyond those living in the most deprived areas.

scholarly journals RACIAL DISPARITIES IN ACCESS TO AND COST OF HEALTHCARE AMONG OLDER ADULTS WITH COGNITIVE LIMITATION: 2002 TO 2016

2019 ◽  
Vol 3 (Supplement_1) ◽  
pp. S564-S564
Author(s):  
Elham Mahmoudi
Keyword(s):  
Older Adults ◽  
Prescription Drugs ◽  
Linear Models ◽  
Medical Expenditure Panel Survey ◽  
Ethnic Disparities ◽  
Office Visit ◽  
Medical Expenditure ◽  
Office Visits ◽  
Vulnerable Subpopulations ◽  
Racial Ethnic

Abstract Using 2002-2016 Medical Expenditure Panel Survey, we examined racial/ethnic disparities in office-visits and prescription-drugs among individuals with cognitive limitation (CL). Medicare beneficiaries (65+) with CL (N=9,369) were included. We used generalized linear models. Prevalence of CL increased overtime among all racial/ethnic groups. Our findings indicate that 96% of Whites vs. 93% of Blacks had at least one office visit (diff=0.03; 95% CI:0.01-0.04). Whites had 2 (95% CI: 1.0-0.4) and 4 (95% CI: 2.5-6.0) more office visits compared with Hispanics and Asians; and used 4 (95% CI: 1-6.9), 5 (95% CI:1.0-9.3) and 6 (95% CI: 1.0-11.5) more prescriptions than their Blacks, Hispanics, and Asians, respectively. Whites had higher annual expenditures for office-visits compared with Asians ($889; 95% CI:409-1,368) and higher expenditures for prescriptions compared with Blacks ($484; 95% CI:$151-$816) and Asians ($546; 95% CI:$28-$1064), respectively. Disparities in care among older adults with CL may put vulnerable subpopulations at a higher risk.

scholarly journals Changes in presentations with features potentially indicating cancer in primary care during the COVID-19 pandemic: a retrospective cohort study

BMJ Open ◽  
2021 ◽  
Vol 11 (5) ◽  
pp. e050131
Author(s):  
Lauren J Scott ◽  
Mairead Murphy ◽  
Sarah Price ◽  
Rhys Lewis ◽  
Rachel Denholm ◽  
...  
Keyword(s):  
Primary Care ◽  
Cohort Study ◽  
Retrospective Cohort Study ◽  
Retrospective Cohort ◽  
Signs And Symptoms ◽  
Patient Characteristics ◽  
Face To Face ◽  
Number Of Patients ◽  
Potential Cancer ◽  
Remote Consultations

ObjectivesTo investigate how the COVID-19 pandemic affected the number of people aged 50+ years presenting to primary care with features that could potentially indicate cancer, and to explore how reporting differed by patient characteristics and in face-to-face vs remote consultations.Design, setting and participantsA retrospective cohort study of general practitioner (GP), nurse and paramedic primary care consultations in 21 practices in South-West England covering 123 947 patients. The models compared potential cancer indicators reported in April–July 2019 with April–July 2020.Main outcome measuresPotential indicators of cancer were identified using code lists for symptoms, signs, test results and diagnoses listed in the National Institute for Health and Care Excellence suspected cancer referral guidance (NG12).ResultsDuring April–July 2019, 17% of registered patients aged 50+ years reported a potential cancer indicator in a consultation with a GP or nurse. During April–July 2020, this reduced to 11% (incidence rate ratio (IRR) 0.64, 95% CI 0.62 to 0.67, p<0.001). Reductions in potential cancer indicators were stable across age group, sex, ethnicity, index of multiple deprivation quintile and shielding status, but less marked in patients with mental health conditions than without (IRR 0.75, 95% CI 0.72 to 0.79, interaction p<0.001). Proportions of GP consultations with potential indicators of cancer reduced between 2019 and 2020 for face-to-face consultations (IRR 0.84, 95% CI 0.76 to 0.92, p<0.001) and increased for remote consultations (IRR 1.17, 95% CI 1.07 to 1.29, p=0.001), although it remained lower in remote consulting than face-to-face in April–July 2020. This difference was greater for nurse/paramedic consultations (face-to-face: IRR 0.61, 95% CI 0.44 to 0.83, p=0.002; remote: IRR 1.60, 95% CI 1.10 to 2.333, p=0.014).ConclusionThe number of patients consulting with presentations that could potentially indicate cancer reduced during the first wave of the COVID-19 pandemic. Patients should be encouraged to continue contacting primary care for persistent signs and symptoms, and GPs and nurses should be encouraged to probe patients for further information during remote consulting, in the absence of non-verbal cues.

scholarly journals Scope of Practice and Patient Panel Size of Family Physicians Who Work With Nurse Practitioners or Physician Assistants

2019 ◽  
Vol 51 (4) ◽  
pp. 311-318 ◽  
Author(s):  
Mingliang Dai ◽  
Richard C. Ingham ◽  
Lars E. Peterson
Keyword(s):  
Primary Care ◽  
Family Medicine ◽  
Nurse Practitioners ◽  
Family Physicians ◽  
Physician Assistants ◽  
Scope Of Practice ◽  
Certification Examination ◽  
Panel Size ◽  
Practice Characteristics ◽  
Number Of Patients

Background and Objectives: Little is known about how the presence of nurse practitioners (NPs) and physician assistants (PAs) in a practice impacts family physicians’ (FPs’) scope of practice. This study sought to examine variations in FPs’ practice associated with NPs and PAs. Methods: We obtained data from American Board of Family Medicine practice demographic questionnaires completed by FPs who registered for the Family Medicine Certification Examination during 2013-2016. Scope of practice score was calculated for each FP, ranging from 0-30 with higher numbers equating to broader scope of practice. FPs self-reported patient panel size. Primary care teams were classified into NP only, PA only, both NP and PA, or no NP or PA. We estimated variation in scope and panel size with different team configurations in regression models. Results: Of 27,836 FPs, nearly 70% had NPs or PAs in their practice but less than half (42.5%) estimated a panel size. Accounting for physician and practice characteristics, the presence of NPs and/or PAs was associated with significant increases in panel sizes (by 410 with PA only, 259 with NP only and 245 with both; all P&lt;0.05) and in scope score (by 0.53 with PA only, 0.10 with NP only and 0.51 with both; all P&lt;0.05). Conclusions: We found evidence that team-based care involving NPs and PAs was associated with higher practice capacity of FPs. Working with PAs seemed to allow FPs to see a greater number of patients and provide more services than working with NPs. Delineation of primary care team roles, responsibilities and boundaries may explain these findings.

Fever in Pediatric Primary Care: Occurrence, Management, and Outcomes

PEDIATRICS ◽  
2000 ◽  
Vol 105 (Supplement_2) ◽  
pp. 260-266
Author(s):  
Jonathan A. Finkelstein ◽  
Cindy L. Christiansen ◽  
Richard Platt
Keyword(s):  
Primary Care ◽  
Laboratory Testing ◽  
Office Visit ◽  
Pediatric Primary Care ◽  
Care Practice ◽  
Meningococcal Sepsis ◽  
Office Visits ◽  
Health Maintenance ◽  
Entire Cohort

Objective. To describe the epidemiology, management, and outcomes of children with fever in pediatric primary care practice. Patients. A cohort of 20 585 children 3 to 36 months of age cared for in 11 pediatric offices of a health maintenance organization between 1991 and 1994. Methods. Using automated medical records we identified all office visits with temperatures ≥38°C for a random sample of 5000 children, and analyzed diagnoses conferred, laboratory tests performed, and antibiotics prescribed. We also determined the frequency of in-person and telephone follow-up after initial visits for fever. Finally, we reviewed hospital claims data for the entire cohort of 20 585 to identify cases of meningitis, meningococcal sepsis, and death from infection. Results. Among 3819 initial visits of an illness episode, 41% of children had no diagnosed bacterial or specific viral source. Of these, 13% with a temperature of 38°C to 39°C and 36% with a temperature of ≥39°C received laboratory testing. Almost half (43%) received some documented follow-up care in the subsequent 7 days. Among the 26 970 child-years of observation in the entire cohort, 15 children (56 per 100 000 child-years) were treated for bacterial meningitis or meningococcal sepsis. Five had an office visit for fever in the week before hospitalization, but only 1 had documented fever ≥39°C and received neither laboratory testing for occult bacteremia nor treatment with an antibiotic. Conclusion. The majority of febrile children in ambulatory settings were diagnosed with a bacterial infection and treated with an antibiotic. Of highly febrile children without a source, 36% received laboratory testing consistent with published expert recommendations, and short-term follow-up was common. Meningitis or death after an office visit for fever without a source was predictably rare. These data suggest that increased testing and/or treatment of febrile children beyond the rates observed here are unlikely to affect population rates of meningitis substantially.

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

2011 ◽  
Vol 2011 ◽  
pp. 1-6 ◽  
Author(s):  
Marek K. Dobke ◽  
Dhaval Bhavsar ◽  
Fernando Herrera
Keyword(s):  
Primary Care ◽  
Primary Care Physicians ◽  
Wound Care ◽  
Care Program ◽  
Primary Care Providers ◽  
Care Providers ◽  
Face To Face ◽  
Telemedicine Consultation ◽  
Number Of Patients ◽  
One Year

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.

scholarly journals The Association between Hospital-Physician Vertical Integration and Outpatient Physician Prices Paid by Commercial Insurers: New Evidence

2021 ◽  
Vol 58 ◽  
pp. 004695802199127
Author(s):  
James Godwin ◽  
Daniel R. Arnold ◽  
Brent D. Fulton ◽  
Richard M. Scheffler
Keyword(s):  
Primary Care ◽  
Vertical Integration ◽  
Fixed Effects ◽  
Office Visit ◽  
Relative Price ◽  
Office Visits ◽  
Hospital Physician ◽  
Regulatory Review ◽  
Price Increases ◽  
Level Hospital

This study assessed the relationship between hospital ownership of physician organizations (known as hospital-physician vertical integration) and facility fees billed to commercial insurers and physician service prices. Healthcare claims came from the IBM® MarketScan® Commercial Database (2012-2016, N = 30,716,800 office visit claims [CPT codes 99211-99215]), and hospital-physician vertical integration measures were from SK&A Office Based Physicians Database provided by IQVIA. Multi-variate, fixed-effect models were used to regress prices on market-level hospital-physician vertical integration; models included geographic market and year fixed effects, claim-level variables, and time-varying market-level variables. Analyses did not find that market-level hospital-physician vertical integration was associated with the billing of facility fees for office visits. However, vertical integration was associated with office visit physician prices for some specialties. A 10-percentage-point increase in vertical integration was associated with a 1.0% price increase for primary care, a 0.6% increase for orthopedics, and a 0.5% increase for cardiology; no such association was found for obstetrics/gynecology or oncology. When comparing metropolitan statistical areas (MSAs) in the bottom quartile of changes in vertical integration from 2012 to 2016 to MSAs in the top quartile, we found the following relative price increases based on predicted values for claims in the top quartile: $1.64 (1.9% of mean 2012 predicted price) for primary care to $2.30 (3.1%) for orthopedics to $3.13 (3.4%) for cardiology. Differences in predicted price accounted for an estimated $45.8 million in additional expenditure on primary care office visits in the top quartile of MSAs in 2016. In summary, market-level hospital-physician vertical integration was positively associated with physician prices for select specialties, but was not associated with changes in the use of facility-fee billing. More evidence on the quality effects of hospital-physician vertical integration is needed, as price increases that are not accompanied by measurable quality improvements should be part of any regulatory review.

scholarly journals Health care utilization following “digi-physical” assessment compared to physical assessment for infectious symptoms in primary care

2022 ◽  
Vol 23 (1) ◽  
Author(s):  
Artin Entezarjou ◽  
Maria Sjöbeck ◽  
Patrik Midlöv ◽  
Veronica Milos Nymberg ◽  
Lina Vigren ◽  
...  
Keyword(s):  
Primary Care ◽  
Health Care ◽  
Health Care Utilization ◽  
Physical Examination ◽  
Office Visit ◽  
Urinary Symptoms ◽  
Care Utilization ◽  
Office Visits ◽  
Physical Concept ◽  
Physical Assessment

Abstract Background The use of chat-based digital visits (eVisits) to assess infectious symptoms in primary care is rapidly increasing. The “digi-physical” model of care uses eVisits as the first line of assessment while assuming a certain proportion of patients will inevitably need to be further assessed through urgent physical examination within 48 h. It is unclear to what extent this approach can mitigate physical visits compared to assessing patients directly using office visits. Methods This pre-COVID-19-pandemic observational study followed up “digi-physical” eVisit patients (n = 1188) compared to office visit patients (n = 599) with respiratory or urinary symptoms. Index visits occurred between March 30th 2016 and March 29th 2019. The primary outcome was subsequent physical visits to physicians within two weeks using registry data from Skåne county, Sweden (Region Skånes Vårddatabas, RSVD). Results No significant differences in subsequent physical visits within two weeks (excluding the first 48 h) were noted following “digi-physical” care compared to office visits (179 (18.0%) vs. 102 (17.6%), P = .854). As part of the “digital-physical” concept, a significantly larger proportion of eVisit patients had a physical visit within 48 h compared to corresponding office visit patients (191 (16.1%) vs. 19 (3.2%), P < .001), with 150 (78.5%) of these eVisit patients recommended some form of follow-up by the eVisit physician. Conclusions Most eVisit patients (68.9%) with respiratory and urinary symptoms have no subsequent physical visits. Beyond an unavoidable portion of patients requiring urgent physical examination within 48 h, “digi-physical” management of respiratory and urinary symptoms results in comparable subsequent health care utilization compared to office visits. eVisit providers may need to optimize use of resources to minimize the proportion of patients being assessed both digitally and physically within 48 h as part of the “digi-physical” concept. Trial registration Clinicaltrials.gov identifier: NCT03474887.

scholarly journals Implementation of Targeted Screening for Poverty in a Large Primary Care Team in Toronto, Canada: A Feasibility Study

2021 ◽  
Author(s):  
Kimberly Wintemute ◽  
Meh Noor ◽  
Aashka Bhatt ◽  
Gary Bloch ◽  
Suja Arackal ◽  
...  
Keyword(s):  
Primary Care ◽  
Screening Program ◽  
Office Visit ◽  
Care Team ◽  
Primary Care Team ◽  
Community Based ◽  
Implementation Evaluation ◽  
Number Of Patients ◽  
Targeted Screening ◽  
Deprived Areas

Abstract BackgroundPoverty has a significant influence on health. Efforts to optimize income and reduce poverty could make a difference to the lives of patients and their families. Routine screening for poverty in primary care is an important first step but rarely occurs in Canada. We aimed to implement a targeted screening and referral process in a large, distributed primary care team in Toronto, Ontario, Canada.MethodsThis implementation evaluation was conducted with a large community-based primary care team in north Toronto. The primary care team serves relatively wealthy neighborhoods that contain pockets of poverty. Physicians were invited to participate. We implemented targeted screening by combining census information on neighborhood-level deprivation with postal codes in patient records. For physicians agreeing to participate, we added prompts to screen for poverty to the charts of adult patients living in the most deprived areas. Standardized electronic medical record templates recommended a referral to a team case worker for income optimization, for those patients screening positive. We recorded the number and percentages of participants at each stage, from screening to receiving advice on income optimization. ResultsThe primary care team included 86 physicians distributed across 19 clinical locations. Thirty-four physicians (39%) participated. Their practices provided care for 27,290 patients aged 18 or older; 852 patients (3%) were found to be living in the most deprived neighborhoods. 509 (60%) had at least one office visit over the 6 months of follow up, and 128 (25%) of those seen were screened. Only 25 (20%) of these patients screened positive for poverty, and 13 (52%) were referred. Eight patients (62% of those referred) were ultimately seen by a caseworker for income optimization.Discussion & ConclusionsWe implemented a targeted poverty screening program combined with resources to optimize income for patients in a large, distributed community-based primary care team. However, only a small number of patients were identified and linked to the intervention Further efforts to scale and spread screening and mitigation of poverty are warranted; these should include broadening the targeted population beyond those living in the most deprived areas.

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