Background

Although many specialists serve as primary care physicians (PCPs), the type of patients they serve, the range of services they provide, and the quality of care they deliver is uncertain.

Objective

To describe trends in patient, physician, and visit characteristics, and compare visit-based quality for visits to generalists and specialists self-identified as PCPs.

Design

Cross-sectional study and time trend analysis.

Data

Nationally representative sample of visits to office-based physicians from the National Ambulatory Medical Care Survey, 1997-2010.

Main measures

Proportions of primary care visits to generalist and specialists, patient characteristics, principal diagnoses, and quality.

Key results

Among 84,041 visits to self-identified PCPs representing an estimated 4.0 billion visits, 91.5 % were to generalists, 5.9 % were to medical specialists and 2.6 % were to obstetrician/gynecologists. The proportion of PCP visits to generalists increased from 88.4 % in 1997 to 92.4 % in 2010, but decreased for medical specialists from 8.0 % to 4.8 %, p = 0.04). The proportion of medical specialist visits in which the physician self-identified as the patient's PCP decreased from 30.6 % in 1997 to 9.8 % in 2010 (p < 0.01). Medical specialist PCPs take care of older patients (mean age 61 years), and dedicate most of their visits to chronic disease management (51.0 %), while generalist PCPs see younger patients (mean age 55.4 years) most commonly for new problems (40.5 %). Obstetrician/gynecologists self-identified as PCPs see younger patients (mean age 38.3 p < 0.01), primarily for preventive care (54.0 %, p < 0.01). Quality of care for cardiovascular disease was better in visits to cardiologists than in visits to generalists, but was similar or better in visits to generalists compared to visits to other medical specialists.

Conclusions

Medical specialists are less frequently serving as PCPs for their patients over time. Generalist, medical specialist, and obstetrician/gynecologist PCPs serve different primary care roles for different populations. Delivery redesign efforts must account for the evolving role of generalist and specialist PCPs in the delivery of primary care.

Background

Headache is a frequent complaint and among the most common reasons for visiting a physician.

Objective

To characterize trends from 1999 through 2010 in the management of headache.

Design

Longitudinal trends analysis.

Data

Nationally representative sample of visits to clinicians for headache from the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey, excluding visits with "red flags," such as neurologic deficit, cancer, or trauma.

Main measures

Use of advanced imaging (CT/MRI), opioids/barbiturates, and referrals to other physicians (guideline-discordant indicators), as well as counseling on lifestyle modifications and use of preventive medications including verapamil, topiramate, amitriptyline, or propranolol (guideline-concordant during study period). We analyzed results using logistic regression, adjusting for patient and clinician characteristics, and weighted to reflect U.S. population estimates. Additionally, we stratified findings based on migraine versus non-migraine, acute versus chronic symptoms, and whether the clinician self-identified as the primary care physician.

Key results

We identified 9,362 visits for headache, representing an estimated 144 million visits during the study period. Nearly three-quarters of patients were female, and the mean age was approximately 46 years. Use of CT/MRI rose from 6.7% of visits in 1999-2000 to 13.9% in 2009-2010 (unadjusted p < 0.001), and referrals to other physicians increased from 6.9 % to 13.2% (p = 0.005). In contrast, clinician counseling declined from 23.5 % to 18.5% (p = 0.041). Use of preventive medications increased from 8.5 % to 15.9% (p = 0.001), while opioids/barbiturates remained unchanged, at approximately 18%. Adjusted trends were similar, as were results after stratifying by migraine versus non-migraine and acute versus chronic presentation. Primary care clinicians had lower odds of ordering CT/MRI (OR 0.56 [0.42, 0.74]).

Conclusions

Contrary to numerous guidelines, clinicians are increasingly ordering advanced imaging and referring to other physicians, and less frequently offering lifestyle counseling to their patients. The management of headache represents an important opportunity to improve the value of U.S. healthcare.

Purpose

High-quality, comprehensive care of vulnerable populations requires interprofessional ambulatory care teams skilled in addressing complex social, medical, and psychological needs. Training health professionals in interprofessional settings is crucial for building a competent future workforce. The impacts on care utilization of adding continuity trainees to ambulatory teams serving vulnerable populations have not been described. We aim to understand how the addition of interprofessional trainees to an ambulatory clinic caring for Veterans experiencing homelessness impacts medical and mental health services utilization.

Methods

Trainees from five professions were incorporated into an interprofessional ambulatory clinic for Veterans experiencing homelessness starting in July 2016. We performed clinic-level interrupted time series (ITS) analyses of pre- and post-intervention utilization measures among patients enrolled in this training continuity clinic, compared to three similar VA homeless clinics without training programs from October 2015 to September 2018.

Results

Our sample consisted of 37,671 patient- months. There was no significant difference between the intervention and comparison groups' post-intervention slopes for numbers of primary care visits (difference in slopes =-0.16 visits/100 patients/month; 95% CI -0.40, 0.08; p=0.19), emergency department visits (difference in slopes = 0.08 visits/100 patients/month; 95% CI -0.16, 0.32; p=0.50), mental health visits (difference in slopes = -1.37 visits/month; 95% CI -2.95, 0.20; p= 0.09), and psychiatric hospitalizations (-0.005 admissions/100 patients/month; 95% CI -0.02, 0.01; p= 0.62). We found a clinically insignificant change in medical hospitalizations.

Conclusions

Adding continuity trainees from five health professions to an interprofessional ambulatory clinic caring for Veterans experiencing homelessness did not adversely impact inpatient and outpatient care utilization. An organized team-based care approach is beneficial for vulnerable patients and provides a meaningful educational experience for interprofessional trainees by building health professionals' capabilities to care for vulnerable populations.