Primary Care: Is There Enough Time for Prevention?

Yarnall, Kimberly S. H.; Pollak, Kathryn I.; Østbye, Truls; Krause, Katrina M.; Michener, J. Lloyd

doi:10.2105/ajph.93.4.635

Cited by 1,377 publications

(1,020 citation statements)

References 34 publications

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“…[39][40][41] Current delivery and reimbursement structures fail to support providers' ability to comprehensively deliberate with patients about the risks and benefits of alternative treatment options and preventive strategies. 42,43 Engaging in shared decision-making to prioritize treatments for a given person is likely to take more time-not less-and is less amenable to standard protocol. 4,5,41 Findings from this study and others 6,44 suggest a role for family perspectives in the measurement of treatment burden and in discussions about prioritization of care.…”

Section: Discussionmentioning

confidence: 99%

A Look at Person-Centered and Family-Centered Care Among Older Adults: Results from a National Survey

Wolff

Boyd

2015

J GEN INTERN MED

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BACKGROUND:Person-centered and family-centered care represents the pinnacle of health care quality, but delivering it is challenging, as is assessing whether it has occurred. Prior studies portray older adults as passive in health decisions and burdened by care-but emphasize age-based differences or focus on vulnerable subgroups. OBJECTIVES: We aimed to examine domains of person-centered and family-centered care among older adults and whether the social context in which older adults manage their health relates to preferences for participating in health decisions and experiences with care. DESIGN AND PARTICIPANTS: This was an observational study of a nationally representative survey of adults aged 65+ years, conducted in concert with the 2012 National Health and Aging Trends Study (n=2040). MAIN MEASURES: Approach to managing health (selfmanage, co-manage, delegate); preferences for making health care decisions with: (1) doctors, (2) family/close friends; and experiences with care pertaining to treatment burden were measured. KEY RESULTS: Approximately two-thirds of older adults self-manage (69.4 %) and one-third comanage (19.6 %) or delegate (11.0 %) health care activities. The majority prefer an independent or shared role when making health decisions with doctors (84.7 %) and family/close friends (95.9 %). Nearly four in ten older adults (37.9 %) experience treatment burden-that managing health care activities are sometimes or often hard for either them or their family/close friends, that health care activities get delayed or don't get done, or that they are cumulatively too much to do. Relative to older adults who self-manage, those who delegate health care activities are more likely to prefer to share or leave health decisions to doctors (aOR=1.79 (95 % CI, 1.37-2.33) and family/close friends (aOR=3.12 (95 % CI, 2.23-4.36), and are more likely to experience treatment burden (aOR= 2.37 (95 % CI, 1.61-3.47). CONCLUSIONS: Attaining person-centered and familycentered care will require strategies that respect diverse decision-making preferences, minimize treatment burden, and support the broader social context in which older adults manage their health.

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Section: Discussionmentioning

confidence: 99%

A Look at Person-Centered and Family-Centered Care Among Older Adults: Results from a National Survey

Wolff

Boyd

2015

J GEN INTERN MED

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“…Only 7% to 28% of female patients report being asked about abuse by health care professionals (27,28). According to one estimate, the average primary care physician would need to devote over seven hours of every working day just to deliver existing federally recommended screening and preventive services (29). Because of the unlikelihood that screening for trauma will become standard in primary care in the near future, primary care physicians should remain alert for clinical indications of recent trauma.…”

Section: Discussionmentioning

confidence: 99%

Assault and Mental Disorders: A Cross-Sectional Study of Urban Adult Primary Care Patients

Glover¹,

Olfson²,

Gameroff³

et al. 2010

Psychiatric Services

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Objective This study estimated the strength of associations between self-reported assault and psychiatric disorders among low-income, urban primary care patients who were predominantly female. Methods A sample of adult patients who consecutively presented at an urban primary care practice completed the Life Events Checklist (N=1,157). They were also screened for current major depression, panic disorder, generalized anxiety disorder, and substance use disorders with the Primary Care Evaluation of Mental Disorders Patient Health Questionnaire; for bipolar disorder with the Mood Disorder Questionnaire; and for posttraumatic stress disorder (PTSD) with the PTSD Checklist–Civilian Version. A total of 977 of the respondents reported whether they had ever experienced an assault. Logistic regression was used to model associations between self-reported assault and screen status, controlling for relevant sociodemographic and clinical characteristics. Results Twenty-five percent of study participants endorsed a history of physical or sexual assault. Compared with patients without a history of assault, patients with a history of assault had significantly greater odds of screening positive for PTSD (odds ratio [OR]=1.97, 95% confidence interval [CI]=1.19–3.25), alcohol use disorder (OR=2.17, CI=1.07–4.41), and drug use disorder (OR=3.38, CI=1.14–9.98). Conclusion A history of assault was related to risk of screening positive for PTSD and a substance use disorder. These findings support assessment of trauma history among low-income primary care patients.

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“…Providers describe behind-the-scenes burdens of documentation, phone calls, emails, refills, consultations, and lab reports, while careful calculations show that guideline-driven preventive care would add 7 h to each primary care clinician's workday. 2 The work of primary care simply cannot be completed in the time allotted.Consequences for Patients. Increased work during short (<20 min) visits means appointments in which fewer health care issues are addressed and the depth of understanding is diminished.…”

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confidence: 99%

The End of the 15–20 Minute Primary Care Visit

Linzer

Bitton

et al. 2015

J GEN INTERN MED

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Sign on a print shop door:BWe can do it fast, we can do it well, we can do it cheap. Pick two.Â 78-year-old widow with hypertension, osteoarthritis, a recent stroke, elevated cholesterol, and a 50-pack-year smoking history comes to her primary care provider for a mild cough and weight loss. She lives alone and loves to chat with her doctor. The physical examination is unrevealing. Chest xray shows a lung nodule. A CT scan is ordered. A long discussion ensues about what would happen if the CT scan shows cancer: how would she undergo evaluation and treatment with her family far away? For what became a 40-min visit, only 15 min had been allotted. Now the doctor is behind schedule. She feels guilty and gives more time to each patient, thus falling further behind. Screening issues are postponed and personal interactions are diminished. A walk-in patient is added. One waiting patient leaves angrily. At the end of the day, facing a large pile of forms and documentation needs, the doctor feels drained and questions the quality of care she provided.The Time Crunch. While Mechanic demonstrated that routine primary care visits (averaging 15-20 min) were 1 to 2 min longer than before, 1 the complexity of clinical issues addressed during these visits has increased. In 2010, the CDC reported that one-third of elderly patients had three or more chronic medical conditions, with 40 % of patients taking three or more medications. Providers may respond by cutting corners on the history and physical examination and by ordering more tests, which lead to a cascade of follow-up tests. Providers describe behind-the-scenes burdens of documentation, phone calls, emails, refills, consultations, and lab reports, while careful calculations show that guideline-driven preventive care would add 7 h to each primary care clinician's workday. 2 The work of primary care simply cannot be completed in the time allotted.Consequences for Patients. Increased work during short (<20 min) visits means appointments in which fewer health care issues are addressed and the depth of understanding is diminished. Time-consuming psychosocial determinants of health are left unaddressed. These consequences translate to decreased patient satisfaction, excess emergency room usage and non-adherence to treatment plans. 3Consequences for Providers. Fifty-three percent of primary care providers report time pressure in the clinical encounter. 4 Many providers describe emotional exhaustion and the fear of making clinical errors. Students observe harried primary care providers and choose alternative career paths.Root Causes. In the early 1990s, Medicare adopted the relative value unit (RVU) payment model. In a budgetneutral system, the introduction of new procedures at substantially higher RVU levels has resulted in the devaluing of cognitive care such as evaluation and management services. When private insurers and managed care contracts reduced compensation, providers increased daily volumes to maintain stable incomes. Health systems followed with daily visit

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Primary Care: Is There Enough Time for Prevention?

Abstract: Time constraints limit the ability of physicians to comply with preventive services recommendations.

Cited by 1,377 publications

References 34 publications

A Look at Person-Centered and Family-Centered Care Among Older Adults: Results from a National Survey

A Look at Person-Centered and Family-Centered Care Among Older Adults: Results from a National Survey

Assault and Mental Disorders: A Cross-Sectional Study of Urban Adult Primary Care Patients

The End of the 15–20 Minute Primary Care Visit

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