January/February 2016 Annals of Family Medicine tip sheet

January 11, 2016

A series of articles in the January/February issue of Annals examines alternatives to the headlong rush toward large vertically integrated, hospital-dominated systems. Three original research studies and two editorials demonstrate that amidst the movement toward increasing scale, which often requires complicated, explicit and unwieldy systems, it is important not to devalue small, local levels of scale in which simple, personal, implicit systems may function well and meet the particular needs of both clinicians and disadvantaged populations. In his introductory editorial, Annals editor, Kurt Stange, MD, PhD, suggests stakeholders broaden the ideology of reform to test the hypothesis that higher-value personalization, integration, and sustainability may be provided by horizontally integrated systems based on independent large and small primary care practices that are well linked with mental health care and public health, and that selectively purchase vertical integration from hospitals and specialists.

Despite Consolidation Pressures, Most Family Physicians Still in Solo and Small Practices That Provide Vital Care in Rural Areas Despite market forces putting pressure on solo and small family practices to consolidate, researchers find that more than half of family physicians seeking board certification in 2013 worked in small and solo practices. Analysis of demographic survey data from 10,888 family physicians seeking certification through the American Board of Family Medicine in 2013 showed that 36 percent of respondents worked in small practices and 15 percent worked in solo practices. Notably, the researchers also found that small practices were the most likely to be located in a rural setting (20 percent). Moreover, small and solo practices were more common among African-American, Hispanic and experienced physicians who have been in practice more than 30 years. These findings, the authors conclude, raise concerns about the types of physicians and communities that are being disproportionately affected by practice consolidation. The authors point out that the likelihood of having a care coordinator and medical home certification increased with practice size, suggesting that smaller practices are likely missing out on new payment models that are dependent on medical home certification. They call for policies to help small practices continue to advance the Triple Aim and profit from economies of scale without sacrificing the benefits of being small. They conclude extension programs and community health teams have the potential to facilitate transformation within solo and small practices.

Solo and Small Practices: A Vital, Diverse Part of Primary Care

By Winston R. Liaw, MD, MPH, et al

Virginia Commonwealth University, Richmond

Large Independent Primary Care Medical Groups Attractive Option for Physicians and Patients

In the turbulent U.S. health care environment, large independent physician-owned primary care groups offer physicians an attractive employment alternative to hospital or large multispecialty medical groups and can also benefit patients and society. In the first peer-reviewed article on the topic, researchers studied five different primary care physician groups varying in size and location and identified their advantages and disadvantages, as well as the challenges they face. Triangulating survey and interview responses from group leaders, group physicians and external observers, the researchers found the scale of the groups makes it possible for them to develop laboratory and imaging services, health information technology and quality improvement infrastructure, while their multiple practice sites offer patients easy geographic access and the small practice environment that many patients and physicians prefer. The five groups studied had an average size of 148 physicians (range = 49 to 255) of whom an average of 87 percent (range = 69 to 100 percent) were primary care physicians. The authors found the groups differed in the extent to which they engaged in value-based contracting, though all were moving to increase the amount of financial risk they took on for their quality and cost performance. They note that unlike hospital-employed and multi-specialty groups, these independent groups can aim to reduce health care costs without conflicting incentives to fill hospital beds and keep specialist incomes high. Some, however, indicated they were under pressure to sell to organizations that could provide capital for additional infrastructure to engage in value-based contracting and provide substantial income to physicians from the sale. Of note, the groups' physicians reported only moderate satisfaction with their clinical workload and their work-life balance, suggesting that the groups have not fully resolved the difficulties of practicing primary care medicine. The authors conclude that large independent primary care physician groups have the potential to make primary care attractive to physicians and to improve patient care by combining human scale advantages of physician autonomy and the small practice setting with resources that are important to succeed in value-based contracting.

Large Independent Primary Care Medical Groups

By Lawrence P. Casalino, MD, PhD, et al

Weill Cornell Medical College, New York

Editorial: Policies and Partnerships Necessary to Help Small, Independent Primary Care Practices Thrive in a Value-Based System

In an editorial, Farzad Mostashari, MD, CEO of Aledade Inc., asserts that preserving small, independent primary care practices, which account for about one-half of all family medicine physicians, is central to the future of health care, but he contends they must band together in order to thrive in a value-based system. Mostashari cites recent evidence demonstrating small practices have lower average cost per patient, fewer preventable hospital admissions and lower readmission rates than larger, independent- and hospital-owned practices. In contrast, the main effect of consolidation, he asserts, is not true clinical integration but market power used to extract higher prices from payers and to prevent any efficiencies from being passed on to payers and consumers. Mostashari calls for solo and small practices to link up with others who share a dedication to the mission of value-based care and the value of small practices. He lays out numerous benefits of this coupling: it provides a collaborative network of peers, allows for insights from population health models, provides scale needed to negotiate value-based contracts and spread risk, and enables practices to procure the necessary technologies and employ individuals who can use analytics to draw insights from data or have the regulatory and billing know-how for a practice to maximize revenue. Moreover, he calls on policymakers and stakeholders to facilitate the partnerships, technologies and policies necessary for small, independent practices to thrive in a value-based health care system.

The Paradox of Size: How Small, Independent Practices Can Thrive in Value-Based Care

By Farzad Mostashari, MD

Aledade, Inc., Bethesda, Maryland

Editorial: External Quality Programs Do Not Make Sense for High-Performing Small Primary Care Practices

Despite the headlong rush of practices toward quality payment, two family physicians from a rural Colorado micro practice explain why their experience suggests it may not make sense for small rural practices. They detail how the practice's many quality improvement initiatives did not result in any improvement -- largely because the practice was already performing at a high level of cost savings and there was little room for improvement. The authors question the validity of current quality reimbursement models, asserting that the Patient-Centered Primary Care Collaborative data does not conclusively show a practice-level improvement in the Triple Aim by movement to the Patient Centered Medical Home. Instead, they contend, these initiatives may be unwittingly driving already high-performing small practices to consolidate or forcing them into larger institutions. They conclude that until there is definitive proof that the surrogate measures of quality from divergent and competing entities, many of whom are seeking to control cost over quality, actually do what they say, practices should fully assess whether the PCMH will improve their practice. The appeal for family medicine and other primary care organizations to be drivers of quality measures that make sense, and rather than joining larger groups or participating in externally driven quality programs, they call for small practices to consider a return to a transparent, free market model such as direct primary care in which there is a direct financial relationship between patients and health care providers in which the consumer judges quality and cost directly.

Achieving PCMH Status May Not be Meaningful for Small Practices

By Kelley K. Glancey and James G. Kennedy

Byers Peak Family Medicine, Winter Park, Colorado

Study Finds No Primary Care Physician Panel Size Threshold Above Which Quality of Care Suffers

Researchers in Canada examine the association of family physicians' panel size with quality of care and health service use. Analyzing quality data on 4,195 physicians in Ontario, Canada, with panel sizes between 1,200 and 3,900 patients, researchers found increasing panel size was associated with small decreases in cancer screening, continuity and comprehensiveness, but little difference in chronic disease management quality or access indicators. Specifically, they found the likelihood of patients' being up-to-date on cervical, colorectal and breast cancer screening showed relative decreases of 8 percent, 6 percent and 5 percent, respectively, with increasing panel size. Eight chronic care indicators showed no significant association with panel size, but increasing panel size was associated with an 11 percent relative increase in hospitalization rates for ambulatory-care-sensitive conditions and an 11 percent decrease in non-emergency department visits. Of note, data did show continuity was highest with medium panel sizes and comprehensiveness had a small decrease with increasing panel size. Because they found no panel size threshold above which quality of care suffered, these findings, they conclude, do not support policy measures such as thresholds or caps that reduce payments to physicians with large panel sizes. They postulate that physicians who take on larger patient panels may be able to do so without compromising care quality because personal or practice characteristics, such as communication style, organizational climate and systematic measures to optimize practice access, allow them to provide effective and efficient care.

Primary Care Physician Panel Size and Quality of Care: A Population-Based Study in Ontario, Canada

By Simone Dahrouge, PhD, et al

University of Ottawa, Canada

Long-Term Opioid Use Associated with Increased Risk of Depression

With more than 200 million prescriptions for opioids written in the United States annually, researchers investigate the association between opioid use and the risk of depression and find opioid-related new onset of depression is associated with duration of use but not dose. Analyzing data on new adult opioid users from three separate health systems: Veterans Health Administration (70,997 patients), Baylor Scott & White Health (13,777 patients) and the Henry Ford Health System (22,981 patients), researchers found the risk of new-onset depression with 31 to 90 days of opioid analgesic use ranged from 1.18 in VHA to 1.33 in HFHS; and in opioid analgesic use more than 90 days, ranged from 1.35 in VHA to 2.05 in HFHS compared to patients who did not use more than 30 days. Dose was not significantly associated with a new onset of depression. The authors conclude that these findings, coupled with previous research, support the conclusion that opioids may cause short-term improvement in mood, but long-term use of more than 30 days is associated with new-onset depression. They speculate that long-term opioid use may cause changes in neuroanatomy, and they call on clinicians to consider the pain-independent contribution of opioid use when depressed mood develops in their patients. They call for further research to identify which patients are most vulnerable to opioid-related depression.

Prescription Opioid Duration, Dose, and Increased Risk of Depression in 3 Large Patient Populations

By Jeffrey F. Scherrer, PhD, et al

Saint Louis University School of Medicine, Missouri

Patients' Willingness to Exchange Different Types of Health Information via Mobile Devices

With the rapid proliferation of mobile devices offering unprecedented opportunities for patients and health care professionals to share health information electronically, researchers examined patients' willingness to electronically exchange different types of health information. They found patients were less willing to exchange via mobile devices information that may be considered sensitive or complex, with age, socioeconomic factors and trust in provider information affecting willingness to participate in mobile health information exchange. Specifically, analyzing data on 3,165 patients, researchers found participants were very willing to exchange appointment reminders, general health tips, medication reminders, laboratory test results, vital signs, lifestyle behaviors and symptoms, as compared to diagnostic information. Although only 15 percent of those surveyed were not at all willing to exchange appointment reminders, overall, 44 percent and 40 percent of respondents were not at all willing to exchange diagnostic information or digital images, respectively. Regardless of the information type, older adults (aged 50 or older) had lower odds of being willing to exchange any type of information compared with younger adults (aged 18 to 34). Education, income and trust in provider information also correlated with greater willingness to exchange many types of information. The authors conclude that information type and demographic group should be considered when developing and tailoring mobile technologies for patient-provider communication. They call on physicians to inform patients of the benefits of mobile health information exchange and to partner with technologists to ensure mobile technologies take into account their patient population and patients' comfort level with such technologies.

Willingness to Exchange Health Information via Mobile Devices: Findings From a Population-Based Survey

By Katrina J. Serrano, PhD, et al

National Cancer Institute, Bethesda, Maryland

High Incidence of New Depressive Symptoms in Chinese Primary Care Patients

Researchers find a high rate of new depressive symptoms in Chinese primary care patients seeking care from physicians in a Hong Kong practice-based research network. Monitoring a consecutive sample of 2,929 adult patients with no past history of physician-diagnosed depression, researchers find a 5 percent cumulative incidence of positive screening for depression, significantly higher than reported in a previous systematic review (3 percent). Predictors for a positive screening included being female, coming from a lower-income household, being a smoker, having at least two comorbidities, having a family history of depression, and having consulted a physician at least twice in the past month. Interestingly, the rate of incident depression was lower among patients seen by physicians with qualifications in both family medicine and psychological medicine, implying the possibility of a preventive benefit of seeing clinicians with joint training. The authors suggest that policies to enhance the training requirements of primary care physicians may help reduce the burden of depressive disorders in Hong Kong. The 12-Month Incidence and Predictors of PHQ-9-screened Depressive Symptoms in Chinese Primary Care Patients

By Weng-Yee Chin, MBBS (UWA), FRACGP

The University of Hong Kong

Alarmingly High Rate of Uncontrolled Hypertension Among Homeless Adults

Researchers at New York University Langone Medical Center find an alarmingly high rate of uncontrolled hypertension among homeless adults using New York City shelter-based clinics. A chart review of a random sample of 210 hypertensive patients found 40 percent of homeless patients had uncontrolled blood pressure, and 16 percent had stage two hypertension. The rates of uncontrolled blood pressure among U.S. hypertensive persons aged 40 to 59 years and 60 to 79 years who are under treatment are 20 percent and 25 percent, respectively. Lack of health insurance was a strong predictor of uncontrolled blood pressure among both homeless and non-homeless hypertensive adults using shelter-based clinics. Interestingly, those with multiple chronic conditions had better hypertension control. The authors assert that considering the significantly higher prevalence of other important risk factors for cardiovascular events among homeless people, effective treatment and better blood pressure control among hypertensive homeless patients is even more important. They propose comprehensive approaches to improve medical insurance, which complicates blood pressure control, and increased social support to improve adherence, targeted health education and lifestyle modifications using mobile health strategies for this transient population.

Rates and Predictors of Uncontrolled Hypertension Among Hypertensive Homeless Adults Using New York City Shelter-Based Clinics

By Ramin Asgary, MD, MPH, et al

New York University School of Medicine

Researchers Offer Pragmatic Alternative for Assessing Home Blood Pressure Control from Patient Diaries

Researchers in Australia offer an empirically validated method for assessing a patient's home blood pressure beyond informally looking over a list of home blood pressure readings or laboriously calculating average blood pressure manually from patient records, which is impractical in busy clinical practice. They found that if three or more of the last 10 home systolic blood pressure readings were ?135 mm Hg (the threshold for elevated blood pressure based on HBP), there was propensity toward having uncontrolled blood pressure according to 24-hour ambulatory blood pressure, as well as greater risk of target organ disease associated with hypertension (increased aortic stiffness, left ventricular relative wall thickness, and left atrial area, but lower left ventricular ejection fraction). They conclude their findings suggest that in patients who do not use home blood pressure devices with storage memory, this pragmatic approach using a summary statistic is a valid aid for physicians to assess blood pressure control. The approach also has the potential to facilitate greater use of HBP monitoring, which has demonstrated superior prognostic utility and helps to reduce health system costs, improve adherence to therapy and achieve better blood pressure control.

Pragmatic Method Using Blood Pressure Diaries to Assess Blood Pressure Control

By James E. Sharman, BHMS (Hons), PhD, et al

University of Tasmania, Menzies Institute for Medical Research, Australia

Office-Based Split-Session Focus Group Interviews Effective for Collecting Data From Health Care Teams

When recruiting health care professionals to participate in focus group interviews, investigators encounter many challenges, including busy clinic schedules, recruitment and getting candid responses from diverse participants. To address these challenges, researchers developed a novel split-session method for conducting focus groups in the practice setting, in which time is divided between sessions with the entire group and with subgroups. They assert the split-session model provides an efficient, effective way to elicit candid qualitative information from all members of a primary care practice in the office setting where they work, simultaneously accommodating the practice's workflow needs as much as possible.

Split-Session Focus Group Interviews in the Naturalistic Setting of Family Medicine Offices

By Michael D. Fetters, MD, MPH, MA, et al

University of Michigan, Ann Arbor

Reflection: Family Physician Shares His Personal Ethos of Healing

A family physician shares his personal ethos of healing that is informed by seven supporting principles -- dignity, authenticity, integrity, transparency, solidarity, generosity and resiliency. The author invites students, residents and practicing physicians to reflect and discover their own ethos of healing and the principles that guide their professional growth, and he offers a short digital documentary to accompany the essay for use as a reflective prompt to encourage personal and professional development.


By William B. Ventres, MD, MA

Oregon Health & Science University, Portland

Reflection: Sleepless Nights Are an Expected Part of Being a Physician

A family physician recounts her experience managing an extremely anxious patient, its influence on her and some of her reflections on the ensuing 'white' nights. She shares how she is often kept awake by the thought that she may have forgotten something for one of her patients and worries that she could have done something better. Any mistakes, or near-mistakes, she writes, lead to endless ruminations, sleepless nights and sudden awakenings, but she concludes that concern for patients and white nights are an expected part of being a physician. The day the terrified awakenings cease, she writes, is when it's time to find a different profession.

White Nights

By Michal Shani, MD, MPH

Clalit Health Service, Rehovot, Israel
Annals of Family Medicine is a peer-reviewed, indexed research journal that provides a cross-disciplinary forum for new, evidence-based information affecting the primary care disciplines. Launched in May 2003, Annals is sponsored by seven family medical organizations, including the American Academy of Family Physicians, the American Board of Family Medicine, the Society of Teachers of Family Medicine, the Association of Departments of Family Medicine, the Association of Family Medicine Residency Directors, the North American Primary Care Research Group, and the College of Family Physicians of Canada. Annals is published six times each year and contains original research from the clinical, biomedical, social and health services areas, as well as contributions on methodology and theory, selected reviews, essays and editorials. Complete editorial content and interactive discussion groups for each published article can be accessed free of charge on the journal's website, http://www.annfammed.org.

Annals of Family Medicine continues to be rated among the most influential journals in general and internal medicine. According to the recently released Thomson Reuters' 2015 Journal Citation Report, the journal's impact factor of 5.434, which measures the average number of citations to recent articles published in the journal, places it number one out of 19 journals in the primary healthcare category and number 16 among 153 journals in the larger category of general and internal medicine. Moreover, Annals' immediacy index rating, which measures the number of times an article is cited in the year it is published, places it at number seven of 153 in the general and internal medicine category. We are proud of these extremely high rankings, which suggest that Annals continues to address timely topics and is publishing articles that are highly relevant to the discipline and to a broad research community.

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