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At least 19 recordsLinked to original sources
PubMed1996

Primary care physicians as gatekeepers in managed care. Primary care physicians' and dermatologists' skills at secondary prevention of skin cancer.

BACKGROUND AND DESIGN: This study determines (1) the readiness of primary care physicians (PCPs) to triage optimally lesions suspicious for skin cancer, (2) the difference in their abilities from those of dermatologists, and (3) whether accurate diagnosis after viewing slide images transfers to accurate diagnosis after viewing lesions on patients. Seventy-one primary care residents and 15 dermatologists and resident dermatologists diagnosed and selected a treatment/diagnostic plan for skin lesions suspicious for cancer. The lesions were shown on slides, computer images, and patients. Participants' performance was compared with biopsy results of all lesions. RESULTS: Dermatologists' scores were almost double those of primary care residents, and primary care residents' performance was positively associated with previous experience in dermatology. Primary care residents failed 50% of the time to diagnose correctly nonmelanoma skin cancer and malignant melanomas, and 33% of the time they failed to recommend biopsies for cancerous lesions. Primary care residents failed to diagnose malignant melanomas 40% of the time; dermatologists failed to do so 26% of the time. Both groups performed better using slide images compared with patients. CONCLUSIONS: Primary care residents may not be ready to assume a gatekeeper role for lesions suspicious for skin cancer. Because of the seriousness of missed diagnoses, especially of malignant melanomas, we need to improve the triage skills of PCPs. Future studies should evaluate whether primary care training allows sufficient time for PCPs to learn the necessary skills. Until we can show that PCPs are prepared to triage optimally, managed care plans should reduce the threshold for referrals to dermatologists of potential skin cancers.

Adult↗
PubMed2002

Managed care, primary care, and the patient-practitioner relationship.

OBJECTIVES: This study examines how specific attributes of managed health plans influence patients' relationships with their primary care practitioners (PCPs) and determines whether these effects are mediated by access to, continuity with, or perceived choice of PCPs. DESIGN, SETTING, PATIENTS: The data source was the nationally representative 1996/97 Community Tracking Study Household Survey (cumulative response rate 65%). The study population (N = 19,415) was composed of 18- to 64-year-old adults whose most recent visit in the past 12 months was made to their primary care delivery site. MAIN OUTCOME MEASURE: Patients' ratings of their interpersonal relationships with their PCPs as measured by a 7-item scale. RESULTS: Gatekeeping arrangements that require patients to select a primary care physician or obtain authorization for specialty referrals were associated with lower ratings of the patient-PCP relationship. Health plan use of a provider network had no effect on the patient-PCP scale score. Although there were no significant differences across any insurance payer categories, uninsured adults rated their relationships with PCPs as significantly poorer than did their insured counterparts. Shorter office waits, having a specific clinician at the primary care site, better perceived choice of PCPs, and a longer duration of relationship with the primary care practitioner were associated with higher ratings of the patient-PCP relationship. Perceived choice of primary care practitioners, but not access to or continuity with PCPs, attenuated some of the negative effects of gatekeeping arrangements on patients' relationships with their primary care practitioners. CONCLUSIONS: Managed health plans that loosen restrictions on provider choice, relax gatekeeping arrangements, or promote access to and continuity with PCPs, are likely to experience higher patient satisfaction with their primary care practitioner relationships. Lack of health insurance impedes the development of patients' relationships with their primary care practitioners.

Adolescent↗
PubMed1996

Managed care, primary care, and quality for children.

In an effort to provide medical care that is both more effective and less costly, the new variants of managed care organizations have instituted a variety of incentives and administrative controls that impact on the types and quantity of care provided to patients. Evidence suggests that the early forms of managed care, namely prepaid group practices, showed particular promise in improving the primary care delivered to children, ie, care that is accessible, person-focused in the long term, comprehensive, coordinated, and oriented toward achieving better outcomes. However, recent evidence concerning the quality of care delivered to children in the newer variants of managed care is mixed and scant; the newer organizational forms may not facilitate and may even have a negative impact on the attainment of primary care. Managed care can have a positive effect on first contact care, because it contractually defines a primary care provider and reduces use of the emergency room as a source of care. It may, however, have mixed effects on other aspects of access and use, depending on the plan's particular characteristics. Longitudinality is threatened by the disruption of prior relationships with out-of-plan providers and by the instability of both enrollees and providers in managed care plans. Children's benefits in managed care arrangements tend to include more preventive services, but access to specialty services has generally been found to be more restrictive. Coordination of care is not inherent to managed care, and many plans are no more likely to foster communication than are traditional indemnity plans. Evidence for the superior clinical quality afforded to children by new variants of managed care is lacking. Because managed care arrangements are proliferating rapidly, better studies are needed to prove or refute the contention that managed care has a significant positive effect on quality of care.

Child↗
PubMed1999

Assessing the critical behavioral competencies of outstanding managed care primary care physicians.

This study used job competence assessment to identify the behavioral characteristics that distinguish outstanding job performances of primary care physicians (PCPs) within a network-model HMO. Primary care physicians were chosen for the study based on six standard performance measures: (1) member satisfaction, (2) utilization, (3) patient complaints, (4) emergency room referrals, (5) out-of-network referrals, and (6) medical record completeness. Outstanding PCPs (N = 16) were identified as those performing within one standard deviation above the mean on all six of the performance measures. A control group of typical PCPs (N = 10) was selected from those performing outside the peer group mean on at least two performance measures. Subjects were administered the Behavioral Event Interview and the Picture Story Exercise. Higher overall competency levels of achievement orientation, concern for personal influence, empathic caregiving, and empowerment drive distinguished outstanding from typical PCPs. Outstanding PCPs also had higher overall frequency of competency in building team effectiveness and interpersonal understanding when compared with typical PCPs. This study suggests that PCP performance is the product of measurable competencies that are potentially amenable to improvement. Competency assessment and development of PCPs may benefit both organizational efficiency and physician and patient satisfaction.

Behavior↗
PubMed2006

On the front lines of care: primary care doctors' office systems, experiences, and views in seven countries.

This 2006 survey of primary care physicians in Australia, Canada, Germany, New Zealand, the Netherlands, the United Kingdom, and the United States reveals striking differences in elements of practice systems that underpin quality and efficiency. Wide gaps exist between leading and lagging countries in clinical information systems and payment incentives. U.S. physicians are among the least likely to have extensive clinical information systems or incentives targeted on quality and the most likely to report that their patients have difficulty paying for care. Disease management capacity varies widely. Overall, findings highlight the importance of nationwide policies: Policy changes in the United States could lead to improved performance.

Ambulatory Care Information Systems↗
PubMed2004

Providing Complementary and Alternative Medicine in primary care: the primary care workers' perspective.

BACKGROUND: The use of Complementary and Alternative Medicine (CAM) in primary care is growing, but still not widespread. Little is known about how CAM can/should be integrated into mainstream care. OBJECTIVES: To assess primary care health professionals' perceptions of need and of some ways to integrate CAM in primary care. METHOD: Questionnaire survey of primary health care workers in Northwest London. General Practitioners (GPs) were targeted in a postal survey, other members of the primary care team, such as district and practice nurses, were targeted via colleagues. The questionnaire assessed health care professionals' perspective on complementary medicine, referrals, ways to integrate complementary medicine into primary care and interest in research on CAM. RESULTS: Responses were obtained from 149 GPs (40% response rate after one reminder) and 24 nurses and 32 other primary care team members. One hundred and seventy-one (83%) respondents had previously referred (or influenced referral) for CAM treatments, the main reasons cited were: patients request (68%), conventional treatments failed (58%) and evidence (36%) (more than one reason could be given). Acupuncture and homoeopathy were the therapies for which patients were most frequently referred, followed by manual therapies. There was a significant interest in more training/information on CAM (66%). Only 12 respondents (6%) were against any integration of CAM in mainstream primary care. Most respondents felt that CAM therapies should be provided by doctors (66%) or other health professionals trained in CAM (82%). Twenty-six percent of respondents agreed with provision of CAM by non-state-registered practitioners. It was felt that the integration of CAM could lead to cost savings (70%), particularly in conditions involving pain, but also cost increases (55%) particularly in 'poorly defined conditions'. Fifty-six percent of respondents would consider participating in studies investigating CAM. The greatest interest was in acupuncture (41% of those who expressed an interest in research), homoeopathy (30%) and therapeutic massage/aromatherapy (26%). CONCLUSIONS: There is considerable interest in CAM among primary care professionals, and many are already referring or suggesting referral. Such referrals are driven mainly by patient demand and by dissatisfaction with the results of conventional medicine. Most of our respondents were in favour of integrating at least some types of CAM in mainstream primary care. There is an urgent need to further educate/inform primary care health professionals about CAM.

Adult↗
PubMed1999

Validation and utility of a self-report version of PRIME-MD: the PHQ primary care study. Primary Care Evaluation of Mental Disorders. Patient Health Questionnaire.

CONTEXT: The Primary Care Evaluation of Mental Disorders (PRIME-MD) was developed as a screening instrument but its administration time has limited its clinical usefulness. OBJECTIVE: To determine if the self-administered PRIME-MD Patient Health Questionnaire (PHQ) has validity and utility for diagnosing mental disorders in primary care comparable to the original clinician-administered PRIME-MD. DESIGN: Criterion standard study undertaken between May 1997 and November 1998. SETTING: Eight primary care clinics in the United States. PARTICIPANTS: Of a total of 3000 adult patients (selected by site-specific methods to avoid sampling bias) assessed by 62 primary care physicians (21 general internal medicine, 41 family practice), 585 patients had an interview with a mental health professional within 48 hours of completing the PHQ. MAIN OUTCOME MEASURES: Patient Health Questionnaire diagnoses compared with independent diagnoses made by mental health professionals; functional status measures; disability days; health care use; and treatment/referral decisions. RESULTS: A total of 825 (28%) of the 3000 individuals and 170 (29%) of the 585 had a PHQ diagnosis. There was good agreement between PHQ diagnoses and those of independent mental health professionals (for the diagnosis of any 1 or more PHQ disorder, kappa = 0.65; overall accuracy, 85%; sensitivity, 75%; specificity, 90%), similar to the original PRIME-MD. Patients with PHQ diagnoses had more functional impairment, disability days, and health care use than did patients without PHQ diagnoses (for all group main effects, P<.001). The average time required of the physician to review the PHQ was far less than to administer the original PRIME-MD (<3 minutes for 85% vs 16% of the cases). Although 80% of the physicians reported that routine use of the PHQ would be useful, new management actions were initiated or planned for only 117 (32%) of the 363 patients with 1 or more PHQ diagnoses not previously recognized. CONCLUSION: Our study suggests that the PHQ has diagnostic validity comparable to the original clinician-administered PRIME-MD, and is more efficient to use.

Adult↗
PubMedDate not supplied

Efficacy and tolerability of finasteride in symptomatic benign prostatic hyperplasia: a primary care study. Primary Care Investigator Study Group.

Because increasing numbers of men are seeking treatment for benign prostatic hyperplasia (BPH) from primary care physicians, we sought to assess the efficacy and tolerability of finasteride in a primary care setting. In this randomized, double-masked study, 2,112 men with symptomatic BPH received either finasteride (n = 1,589) or placebo (n = 523) for 1 year. At 3, 6, 9, and 12 months, urinary symptoms were measured using the American Urological Association Symptom Index (AUASI). Quality of life was assessed using the BPH Impact Index (BII), which assessed bother, worry, physical discomfort, and restriction in activities. Both patients and investigators assessed overall urologic status. Investigators assessed the effect of the drug on plasma lipids in a subset of patients. Patients treated with finasteride had a statistically significant mean decrease in AUASI scores compared with patients treated with placebo beginning at month 6 and continuing throughout the study. At month 12, adjusted mean decreases in AUASI scores were -4.96 for finasteride versus -3.71 for placebo. Statistically significant differences in favor of finasteride were also noted on BII at months 9 and 12. Patient and investigator overall assessments showed greater improvement in the finasteride group beginning at month 6. The incidence of drug-related sexual adverse experiences was significantly greater in finasteride-treated patients but led to withdrawal in only 2.2% of these patients. Overall lipid profile was not significantly altered in either group. Based on improvement in symptoms and quality of life, and on its favorable tolerability profile, finasteride should be considered by primary care physicians for management of symptomatic BPH.

Aged↗
PubMed2006

Developing cancer services strategy in primary care in England: primary care trust managers' views of the primary care cancer leads initiative.

PURPOSE: Primary care cancer lead clinicians (PCCLs) act strategically in primary care trusts (PCTs) in England to improve communication and understanding of cancer across primary and secondary care and provide a link between Cancer Networks and primary care. The aim is to evaluate the first three years of the initiative. DESIGN/METHODOLOGY/APPROACH: A postal questionnaire was sent to all PCT chief executives in all PCTs in England and some were passed on to other PCT managers for completion. The response rate was 61 per cent. PCT directors of public health were the largest group of respondents (29 per cent). Most (74 per cent) PCCLs were GPs and 22 per cent were nurses. FINDINGS: PCCLs were most likely to focus on palliative care and preventive services. Key achievements were identified as raising awareness of cancer, developing relationships and promoting primary care. The personal skills of the PCCLs were important as was support of colleagues at all levels. Lack of time was a major barrier to achievement, as was a lack of understanding of the role from others. Links with the Cancer Networks were being developed. About 85 per cent of managers wanted the role to continue. ORIGINALITY/VALUE: The paper illustrates that PCCLs are at the forefront of improving cancer services in primary care. They are particularly important in view of the priority of reducing premature deaths and promotion of healthy lifestyles.

Attitude of Health Personnel↗