September/October 2014 Annals of Family Medicine Tip Sheet

(Press-News.org) Illinois' Medicaid Primary Care Case Management Program Associated With Substantial Savings, Reductions in Inpatient and Emergency Care and Improvements in Quality Measures Illinois was an early leader in comprehensive Medicaid reform, implementing a primary care case management program, Illinois Health Connect, and a complementary disease management program, Your Healthcare Plus, in 2006. The programs aimed to promote preventive care, reduce the redundancy of services through continuity of care with a primary care provider, and improve the management of chronic diseases. In a study supported by the Commonwealth Fund, researchers analyzed claims and enrollment data from before the Medicaid experiment began through 2010 and found the programs were associated with cost reductions, improved utilization patterns and generally improved quality. Specifically, they found that IHC and YHP were associated with 1) substantial increases in outpatient services; 2) larger decreases in inpatient and emergency services; 3) a reduction of total costs vs. projections; and 4) substantial improvements in most preventive and chronic care measures. Enrollment data showed Illinois Medicaid expanded considerably between 2006 (2,095,699 enrollees) and 2010 (2,692,123 enrollees). Researchers estimate the rate of annual savings was 6.5 percent for IHC and 8.6 percent for YHP by the fourth year, with a cumulative Medicaid savings of $1.46 billion. Further analysis showed that per-beneficiary annual costs fell in Illinois over the study period compared to those in states with similar Medicaid programs. Moreover, quality improved for nearly all metrics under IHC, and most prevention measures more than doubled in frequency. Notably, while Medicaid outpatient costs rose by 33 percent, the increase was more than offset by a 30 percent drop in inpatient costs. Avoidable hospitalizations for YHP fell by nearly 17 percent, and IHC bed-days fell by nearly 16 percent. Emergency department visits declined by 5 percent by 2010. Though these results are robust and encouraging, the researchers caution against making specific causal inferences, and they advise interstate collaboration to help states learn from each other and possibly avoid deleterious policy decisions. Cost, Utilization and Quality of Care: An Evaluation of Illinois' Medicaid Primary Care Case Management Program By Robert L. Phillips, Jr., MD, MSPH, et al
American Board of Family Medicine, Washington, DC

Researchers Propose a New Standard for Conducting Relevant Research in a Rapidly Changing Health Care World The accelerated pressure for change in health care has created an exploding need for relevant and rapidly generated new information, yet the current slow and fragmented approach to research often fails to address practical needs for decision making and is not up to the challenge. Researchers synthesize an emerging "5 R's" standard to guide new research that will better meet the changing needs of health care delivery. They assert that the 5 R's will generate research that 1) is relevant to stakeholders, 2) is rapid and recursive in application, 3) redefines rigor, 4) reports on resources required, and 5) is replicable. The R's of the research process, the authors write, are mutually reinforcing and can be supported by training that fosters collaborative and reciprocal relationships among researchers, implementers and other stakeholders. They offer the 5 R's as a framework for much needed discussion and adjustment of criteria for what is considered high quality research. Consistent and bold application of this standard, they conclude, will increase the value, timeliness and applicability of the research enterprise.

In an accompanying editorial, Bernard G. Ewigman, MD, MSPH, chair of the department of family medicine at the University of Chicago and author of more than 80 peer- reviewed research articles, contends the 5 R's model creates a clear vision for research that would likely hit the targets of the Institute for Healthcare Improvement's "Triple Aim" of improving patient experience of care, improving the health of populations and reducing the per capital cost of health care more consistently and more quickly than our current fragmented approach to health care delivery research. He asserts that the 5 R's model combines the best, most practical, most engaging and most appropriately rigorous methods, habits and processes related to care delivery research that have been developed over the past several decades, and that it synthesizes these elements in a manner that has the potential to systematically accelerate the generation and use of findings of the most meaningful kind. He concludes that the model should not be dismissed as idealistic, unrealistic or overly ambitious; rather, it is a brilliant, innovative and achievable synthesis of many research methods and traditions that not is only feasible, but worthwhile and imperative to pursue to generate research that directly preserves human life and relieves human suffering. The 5 R's: An Emerging Bold Standard for Conducting Relevant Research in a Changing World By C.J. Peek, PhD, et al
University of Minnesota Medical School, Minneapolis Could 5R Research Help Achieve the Triple Aim?
By Bernard G. Ewigman, MD, MSPH
University of Chicago

Successful Bronx Voter Registration Project Demonstrates Power of Health Centers to Give Voice to Disenfranchised Communities A successful voter registration project undertaken at two federally qualified health centers in the Bronx, New York, demonstrates the power of clinics to bring a voice to civically disenfranchised communities. The initiative sought to register clinic patients to vote by engaging patients in clinic waiting areas over a 12-week period between August and October 2012. Volunteers directly engaged with a total of 304 patients. Of the 128 patients who were eligible and not currently registered, 114 (89 percent) registered to vote through the project. Sixty-five percent of new registrants were younger than 40 years of age, and nearly half of new voters were re-registrants because of changes in demographics, highlighting barriers in the current voter registration process. In communities with high levels of socioeconomic stress, the authors write, easing access to voter services becomes increasingly important. This project, they assert, is an instructive example of how health care professionals can address broader social determinants of health through clinic interventions. If health centers step up their role in community civic activism, they conclude, they can act as powerful vehicles for bringing a voice to communities underrepresented in the electoral process. Results of a Voter Registration Project at 2 Family Medicine Residency Clinics in the Bronx, New York By Alisha Liggett, MD, et al
Montefiore Medical Center, Bronx, New York

Social Determinants of Health, Not Use of Ambulatory Care Services, May Explain Disparity in Obstructive Airway Disease Hospitalization Research has previously shown that individuals of lower socioeconomic status have higher rates of hospitalization for ambulatory care-sensitive conditions—conditions for which some hospitalization is thought to be avoidable with successful management in the community. Seeking to tease out the effect of socioeconomic status on hospitalizations for obstructive airway disease in the setting of universal health care where there should be equal access to care regardless of income, researchers find broader social determinants of health, and not differences in ambulatory care use or physicians, may explain the disparity. Analyzing data on 34,741 patients in the city of Winnipeg, Manitoba, Canada, 2 percent of whom were hospitalized with an obstructive airway disease-related diagnosis during the two-year follow-up period, they found an approximately three-fold increase in the odds of being hospitalized in the lowest income group relative to the highest, consistent with previous work. After controlling for patient demographics, ambulatory care use and physician characteristics, however, the relationship between socioeconomic status and hospitalization remained virtually unchanged, contrary to previous suggestions that some of these factors may drive the association. These findings demonstrate that neither differences in the type of care nor the physicians providing the care are driving the disadvantaged to be hospitalized. The authors assert that the results suggest that factors outside of direct contact with the health care system, outside of the physician's office, may lead to the inequity in obstructive airway disease hospitalization. They conclude that these findings should remind clinicians and policy makers of the importance of social determinants of health and encourage the development of programs and policies that address the poverty associated with poor health outcomes. Inequities in Ambulatory Care and the Relationship Between Socioeconomic Status and Respiratory Hospitalizations: A Population-Based Study of a Canadian City By Alan Katz, MBChB, MSc, CCFP, FCFP, et al
University of Manitoba, Winnipeg, Canada

With Fewer Family Physicians Providing Care to Children, Researchers Explore Demographic Characteristics of Family Physicians Providing Pediatric Care Family physicians are the usual source of care for more than one third of children in the United States, yet the absolute proportion of family physicians providing any care to children declined from 78 percent in 2000 to 68 percent in 2009. Given the importance of ensuring access to primary care for all children, researchers sought to better understand the factors associated with the decline, including the demographic and geographic characteristics of family physicians who provide care to children. Analyzing data collected from 37,020 family physicians who took the American Board of Family Medicine Maintenance of Certification Examination between 2006 and 2009, researchers found the overall proportion of family physicians providing care to children declined from 74 percent in 2006 and 2007 to 72 percent in 2008 and 68 percent in 2009. Younger age, female sex and rural location were all positive predictors of family physicians providing care for children. They also found that family physicians practicing in a partnership were more likely to provide care to children than those in group practices, as were family physicians practicing in areas with a higher density of children, lower poverty or no pediatricians. Family physicians, the authors assert, are the vanguard of access for children in many rural, urban and underserved areas. Policy makers and leaders in the pediatric workforce concerned with providing adequate and accessible care to children and families, they conclude, must help family physicians manage the burdens of increasing demands and incentives to care for adults, amidst shifting physician demographics and fluctuating interest in primary care. Factors Influencing Family Physicians' Contribution to the Child Health Care Workforce By Laura Makaroff, DO, et al
The Robert Graham Center: Policy Studies in Family Medicine and Primary Care, Washington, DC

Cost-Effective Strategies for Increasing Patient Portal Use in Primary Care With the continued push to engage patients in care through the use of information technology, researchers examined cost-effective ways small- to medium-sized primary care practices can effectively encourage patients to use online patient portals to access their personal health records. In the study, which was co-funded by the Agency for Healthcare Research and Quality, researchers analyzed data from eight Virginia primary care practices and found that integrating promotion of the portal into the office visit appeared to be more effective at increasing usage rates than mailing invitations and other costly advertising campaigns with results comparable to more elaborate promotion efforts of large integrated systems. Specifically, the researchers found that over the 30-month study period, 26 percent of the 112,893 patients who had an office visit created an account on the patient portal. The monthly increase in users was nearly linear, with an estimated monthly increase of 1 percent. Of patients who visited the practices in the final month, 33 percent had a new or preexisting account. The authors point out that this uptake was significantly greater than the 17 percent observed in a previously conducted efficacy trial, in which the portal was only promoted through mailings. Although critics of patient portals express concerns that online technologies might discriminate against older patients, the researchers found one out of three patients aged 60 to 69 years enrolled, the highest use rate of any age group studied. Moreover, they found that among patients, a key factor influencing use of the patient portal was having a comorbid condition—33 percent of patients with chronic conditions created a patient portal account. Practice-level analysis found that uptake was influenced by the adoption of a team-based approach to notify patients about the patient portal rather than relying solely on clinicians, as well as adding portal features to report laboratory test results and generate after-care summaries. They conclude that by directly engaging patients to use a portal and supporting practices to integrate its use into care, primary care practices can match or surpass the usage rates achieved by large health systems. Engaging Primary Care Patients to Use a Patient-Centered Personal Health Record By Alex H. Krist, MD, MPH, et al
Virginia Commonwealth University, Richmond

The Cost of Cardiac Care in the United States and India: A Story About What Developed Countries can Learn From Developing Countries A health services researcher compares the cost of surgical cardiac care in the United States and India after her Indian mother fell ill while visiting her in the United States. She describes the challenges they faced in making well-informed decisions in the United States due to the lack of cost transparency and the minimal flexibility offered in the choice of care. She describes why they ultimately sought care in India, where cardiac specialty care is world-class with comparable morbidity rates, and the costs are readily available, significantly lower and they were able to freely choose their type of care. She asserts that "developed" countries have a lot to learn from the ways health care is delivered in "developing" countries. Increased transparency, she concludes, is essential for choosing not only the hospital and provider of care, but also the appropriate course of action. A Tale of 2 Countries: The Cost of My Mother's Cardiac Care in the United States and India By Sowmya R. Rao, PhD, et al
University of Massachusetts Medical School, Worcester

Opportunities to Improve Implementation of Case Management for Patients With Dementia With the increasing prevalence of dementia worldwide, researchers in Canada examine the barriers to implementation of case management for dementia patients, which previous research has shown to have limited efficacy. The systemic review of 43 studies finds that those interventions that address a greater number of barriers to implementation result in more positive outcomes. The authors also identify two key conditions that appear to significantly improve case management outcomes: high-intensity case management and effective communication among all health care professionals and services caring for dementia patients. They outline five characteristics of high-intensity case management: 1) a small caseload, 2) regular meetings with patients and caregivers, 3) education on health conditions, 4) close contact with family physicians, and 5) proactive and timely follow up. With regard to communication, they assert that effective communication relies on an efficient referral system and timely support of family physicians and case managers by specialists in complex cases. Barriers to Implementation of Case Management for Patients With Dementia: A Systematic Mixed Studies Review By Isabelle Vedel, MD, PhD, et al
McGill University, Montreal, Quebec, Canada

Standardized Shoe Advice As Effective as Podiatric Treatment for Patients Presenting With Forefoot Pain Consultations for forefoot pain are frequent in primary care, but there is little research to guide treatment options. Researchers in The Netherlands examined outcomes for 205 patients aged 50 years and older consulting for nontraumatic foot pain and find that regardless of whether patients were randomized to consult a podiatrist or receive standard shoe advice by means of an informational leaflet containing advice on shoe characteristics and proper fit, foot pain and foot-related dysfunction improved over time. Based on these findings, the authors conclude that primary care physicians should be cautious when referring a patient to a podiatrist; instead they should start by providing advice on proper characteristics and fit of shoes. Treatment of Forefoot Problems in Older People: A Randomized Clinical Trial Comparing Podiatric Treatment with Standardized Shoe Advice By Babette van der Zwaard
VU University Medical Centre, Amsterdam, The Netherlands

Family Physicians' Diverse Role in Preventing and Guiding End of Life Hospital Admissions Family physicians play a unique role in providing end-of-life care and enabling terminally ill patients to die in familiar surroundings rather than at a hospital. Researchers conducted focus group interviews with 39 family physicians in Belgium to explore their perceptions of their role and the difficulties they have preventing and guiding hospital admissions at the end of life. They identified five key roles assumed by family physicians: 1) as a care planner, anticipating future scenarios; 2) as an initiator of decisions in acute situations, mostly in an advisory manner; 3) as a provider of end-of-life care in which competency and attitude is considered important; 4) as a provider of support, particularly by being available during acute situations; and 5) as a decision maker, taking overall responsibility. Enhancing the family physician's role as a gatekeeper to hospital services, offering physicians more end-of-life care training and developing or expanding initiatives to support them, the authors conclude, could improve end-of-life care in general and prevent hospital admissions at the end of life. The Family Physicians' Perceived Role in Preventing and Guiding Hospital Admissions at the End of Life: A Focus Group Study By Thijs Reyniers, MSc, et al
Vrije Universiteit Brussel & Ghent University, Brussels, Belgium

Defensive Medicine: How a Malpractice Lawsuit Nearly Made One Physician Join the Cadre of Doctors Who Protect Themselves at the Cost of Their Patients' Genuine Care A practicing physician in Israel reflects on how a malpractice suit challenged her customary, patient-centered approach to care. Sharing three vignettes from her practice, Ruth Kannai, MD, describes her inner dialogue both "preprosecution" and "postprosecution" and concludes that prosecuted doctors must not abandon their most fundamental contract with patients, which is to place them at the center, putting patients' needs before their own and sacrificing their own comfort and perhaps even security for them. She asserts that defensive medicine, often practiced by doctors to avert malpractice suits, sacrifices the patient's well-being for the emotional health and sound sleep of the doctor, sometimes at the cost of trying to shift the doctor's responsibility to the patient. And she tells how refocusing on the needs of a single patients helped her to get her perspective back. It Finally Happened to Me By Ruth Kannai, MD
Hebrew University, Jerusalem, Israel

Good Physicians Are Also Interpreters Whose Work to Understand Patients is Vital to the Healing Process A practicing physician examines how working with a predominantly Spanish population reminds him of the importance of understanding patients—not only in the literal sense of being able to understand the patients' language—but in a broader sense of having the courage to ask about the patients' struggles and to invest in helping them overcome them. Good physicians, he asserts, work to forge a common language with all their patients, not only with those who do not speak English. He concludes that to become a doctor is also to become an interpreter. Interpreting Medicine: Lessons From a Spanish-Language Clinic By Benjamin P. Brown, MD
University of Chicago Medical Center

INFORMATION: 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.