Family physician perspectives on primary care reform priorities: a cross-sectional survey.
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ABSTRACT: Background
The province of British Columbia is facing a family physician shortage despite consistent increases in the number of physicians per capita and ongoing reforms to address the shortage. We identify physicians' priorities for structural reform, describe the alignment of those priorities with BC's suite of reforms and compare responses between established physicians and those new to practice; we also assessed rates of burnout.Methods
All family physicians credentialed within Vancouver Coastal Health in 2018 were invited to participate in a cross-sectional survey. Respondents were asked about their practice model and characteristics, demographics, level of burnout and reform priorities. We used χ2 tests and multivariable logistic regression to investigate associations between personal and practice characteristics, burnout and reform priorities.Results
Of the 1017 family physicians invited to participate, 525 (51.6%) responded. Of these, 399 (76.0%) indicated a need for fundamental change to how primary care is delivered; 244 (46.4%) would prefer to be a clinic employee rather than a small business owner. Other reform priorities included options to practise in a team (stated as very important by 69.6% of respondents), direct funding for team roles (66.7%), direct clinic funding (59.8%), part-time work options (64.7%), and ability to take planned vacations and parental leave (81.1%). The importance of individual reform priorities varied based on the participants' model of practice, location and years in practice. Of respondents, 108 (21.1%) had experienced a high level of burnout.Interpretation
Almost half of family physicians would prefer to be employees rather than small business owners and over 20% reported a high level of burnout. Practice models offering direct employment model have very limited availability and are not included in the current suite of reforms in BC, potentially pulling physicians away from community-based family medicine and into other models or specialties.
SUBMITTER: Hedden L
PROVIDER: S-EPMC8157978 | biostudies-literature |
REPOSITORIES: biostudies-literature
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Project description:BACKGROUND:Due to a low birth rate and an aging population, Japan faces an increase in the number of elderly people without children living in single households. These elderly without a spouse and/or children encounter a lack of caregivers because most sources of care for the elderly in Japan are not provided by private agencies but by family members. However, family caregivers not only help with daily living but are also key participants in treatment decision making. The effect of family absence on treatment decision making has not been elucidated, although more elderly people will not have family members to make surrogate decisions on their behalf. OBJECTIVE:The aim is to understand the influence of family absence on treatment decision making by physicians through a cross-sectional online survey with three hypothetical vignettes of patients. METHODS:We conducted a cross-sectional online survey among Japanese physicians using three hypothetical vignettes. The first vignette was about a 65-year-old man with alcoholic liver cirrhosis and the second was about a 78-year-old woman with dementia, both of whom developed pneumonia with consciousness disturbance. The third vignette was about a 70-year-old woman with necrosis of her lower limb. Participants were randomly assigned to either of the two versions of the questionnaires-with family or without family-but methods were identical otherwise. Participants chose yes or no responses to questions about whether they would perform the presented medical procedures. RESULTS:Among 1112 physicians, 454 (40.8%) completed the survey; there were no significant differences in the baseline characteristics between groups. Significantly fewer physicians had a willingness to perform dialysis (odds ratio [OR] 0.55, 95% CI 0.34-0.80; P=.002) and artificial ventilation (OR 0.51, 95% CI 0.35-0.75; P<.001) for a patient from vignette 1 without family. In vignette 2, fewer physicians were willing to perform artificial ventilation (OR 0.59, 95% CI 0.39-0.90; P=.02). In vignette 3, significantly fewer physicians showed willingness to perform wound treatment (OR 0.51, 95% CI 0.31-0.84; P=.007), surgery (OR 0.35, 95% CI 0.22-0.57; P<.001), blood transfusion (OR 0.45, 95% CI 0.31-0.66; P<.001), vasopressor (OR 0.49, 95% CI 0.34-0.72; P<.001), dialysis (OR 0.38, 95% CI 0.24-0.59; P<.001), artificial ventilation (OR 0.25, 95% CI 0.15-0.40; P<.001), and chest compression (OR 0.29, 95% CI 0.18-0.47; P<.001) for a patient without family. CONCLUSIONS:Elderly patients may have treatments withheld because of the absence of family, highlighting the potential importance of advance care planning in the era of an aging society with a declining birth rate.
| S-EPMC6764328 | biostudies-literature
Project description:BackgroundHigher primary care physician supply is associated with lower mortality due to heart disease, cancer and stroke, but its relation to diabetes care and outcomes is unknown. We examined the association between primary care physician supply and evidence-based testing and hospital visits for people with diabetes in naturally occurring multispecialty physician networks in Ontario, Canada.MethodsWe conducted a cross-sectional analysis between Apr. 1, 2009, and Mar. 31, 2011, using linked administrative data. We included all Ontario residents over 40 years of age with a diagnosis of diabetes before Apr. 1, 2007, who were alive on Apr. 1, 2009 (N = 712 681). We tested the association between physician supply and outcomes at the network level using separate Poisson regression models for urban and nonurban physician networks. We accounted for clustering at the physician and network level and adjusted for patient characteristics.ResultsPatients in physician networks with a high supply of primary care physicians were more likely to receive the optimal number of evidence-based tests for diabetes than patients in networks with low primary care physician supply (urban relative risk [RR] 1.06, 95% confidence interval [CI] 1.04-1.07; nonurban RR 1.17, 95% CI 1.14-1.21) but were no different regarding emergency department visits (urban RR 1.05, 95% CI 0.94-1.17; nonurban RR 0.96, 95% CI 0.85-1.08) or hospital admissions for diabetes complications (urban RR 1.01, 95% CI 0.89-1.14; nonurban RR 0.91, 95% CI 0.77-1.07).InterpretationHaving more primary care physicians per capita is associated with better diabetes care but not with reduced hospital visits in this setting. Further research to understand this relation and how it varies by setting is important for resource planning.
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Project description:BACKGROUND:The quality of patient-physician discussions about chronic kidney disease (CKD) in primary care has not been studied previously. STUDY DESIGN:Cross-sectional study. SETTINGS & PARTICIPANTS:We audiotaped encounters between 236 patients with hypertension and their primary care physicians (n = 40). PREDICTORS:Patient, physician, and encounter characteristics. OUTCOMES & MEASUREMENTS:We described the occurrence and characteristics (content, use of technical terms, and physician assessment of patient comprehension of new concepts) of CKD discussions. We assessed patient and physician characteristics associated with CKD discussion occurrence. RESULTS:Many patients (mean age, 59 years) had uncontrolled hypertension (51%), diabetes (44%), and/or 3 or more comorbid conditions (51%). Most primary care physicians practiced (52%) fewer than 10 years. CKD discussions occurred in few (26%; n = 61) encounters, with content focused on laboratory assessment (89%), risk-factor treatment (28%), and causes (26%) of CKD. In encounters that included a CKD discussion, physicians used technical terms (28%; n = 17) and rarely assessed patients' comprehension (2%; n = 1). CKD discussions were statistically significantly less common in visits of patients with some (vs no) college education (OR, 0.23; 95% CI, 0.09-0.56), with 3 or more (vs fewer) comorbid conditions (OR, 0.49; 95% CI, 0.25-0.96), and who saw physicians with more (vs fewer) than 10 years of practice experience (OR, 0.41; 95% CI, 0.21-0.80). CKD discussions were more common during longer encounters (OR, 1.31; 95% CI, 1.04-1.65) and encounters in which diabetes was (vs was not) discussed (OR, 2.87; 95% CI, 1.22-6.77). LIMITATIONS:Generalizability of our findings may be limited. CONCLUSIONS:Patient-physician discussions about CKD in high-risk primary care patients were infrequent. Physicians used technical terms and infrequently assessed patients' understanding of new CKD concepts. Efforts to improve the frequency and content of patient-physician CKD discussions in primary care could improve patients' clinical outcomes.
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Project description:IntroductionThe optimal approach to screening and risk stratification for non-alcoholic fatty liver disease is challenging given disease burden and variable progression. The aim of this study was to assess primary care physician and referring physician practice patterns regarding non-alcoholic fatty liver disease.MethodsAn anonymous nationwide survey was administered to primary care physicians, endocrinologists, and cardiologists in a: (1) tertiary academic hospital, (2) community hospital, and (3) the American College of Physicians Insider Panel. Survey domains assessed non-alcoholic fatty liver disease knowledge, recommendations for screening, risk stratification, treatment, and referral patterns.ResultsA total of 440 providers completed the survey (35.2% completion rate; N = 82 academic hospital, N = 21 community hospital, N = 337 American College of Physicians). Half were male (51.7%), 78% from internal medicine, with 5% subspecialists. Providers were knowledgeable regarding prevalence and risk factors for non-alcoholic fatty liver disease. 58% would support screening for non-alcoholic fatty liver disease and used liver enzymes to do so. Only 22.5% used serum biomarkers and 23% used transient elastography for risk stratification. Primary reason for referral was advanced fibrosis/cirrhosis. 80% reported barriers to treating non-alcoholic fatty liver disease. There was no consistent diet recommended.ConclusionIn this nationwide survey, we demonstrated that while overall disease knowledge was good, there was an important disconnect between current guidelines and real-world clinical practice. There is also significant heterogeneity in practice patterns for first-line therapy of non-alcoholic fatty liver disease and the majority of provider's report barriers to treating non-alcoholic fatty liver disease. These findings highlight the potential role for reevaluating screening and risk stratification recommendations in primary care to better align with needs in that setting.
| S-EPMC8460969 | biostudies-literature
Project description:BackgroundPrimary care physician (PCP) burnout is prevalent and on the rise. Physician burnout may negatively affect patient experience of care.ObjectiveTo identify the direct impact of PCP burnout on patient experience in various domains of care.DesignA cross-sectional observational study using physician well-being (PWB) surveys collected in 2016-2017, linked to responses from patient experience of care surveys. Patient demographics and practice characteristics were derived from the electronic health record. Linked data were analyzed at the physician level.SettingA large non-profit multi-specialty ambulatory healthcare organization in northern California.ParticipantsA total of 244 physicians practicing internal medicine or family medicine who responded to the PWB survey (response rate 72%), and 30,701 completed experience surveys from patients seeing these physicians.MeasurementsBurnout was measured with a validated single-item question with a 5-point scale ranging from (1) enjoy work to (5) completely burned out and seeking help. Patient experience of patient-provider communication, access, and overall rating of provider was measured with Clinician & Group Consumer Assessment of Healthcare Providers & Systems (CG-CAHPS) survey. Patient experience scores (0-100 scale) were adjusted for age, gender, race/ethnicity, and English proficiency.ResultsPhysician burnout had a negative impact on patient-reported experience of patient-provider communication but not on access or overall rating of providers. A one-level increase in burnout was associated with 0.43 decrease in adjusted patient-provider communication experience score (P < 0.01).LimitationsData came from a single large healthcare organization. Patterns may differ for small- and mid-sized practices.ConclusionPhysician burnout adversely affects patient-provider communication in primary care visits. Efforts to improve physician work environments could have a meaningful positive impact on patient experience as well as physician well-being.
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Project description:PurposeDiscontinuation of statin therapy represents a major challenge for effective cardiovascular disease prevention. It is unclear how often primary care physicians (PCPs) re-initiate statins and what barriers they encounter. We aimed to identify PCP perspectives on factors influencing statin re-initiation.MethodsWe conducted six nominal group discussions with 23 PCPs from the Deep South Continuing Medical Education network. PCPs answered questions about statin side effects, reasons their patients reported for discontinuing statins, how they respond when discontinuation is reported, and barriers they encounter in getting their patients to re-initiate statin therapy. Each group generated a list of responses in round-robin fashion. Then, each PCP independently ranked their top three responses to each question. For each PCP, the most important reason was given a weight of 3 votes, and the second and third most important reasons were given weights of 2 and 1, respectively. We categorized the individual responses into themes and determined the relative importance of each theme using a "percent of available votes" metric.ResultsPCPs reported that side effects, especially muscle/joint-related symptoms, were the most common reason patients reported for statin discontinuation (47% of available votes). PCPs reported statin re-challenge as their most common response when a patient discontinues statin use (31% of available votes). Patients' fear of side effects was ranked as the biggest challenge PCPs encounter in getting their patients to re-initiate statin therapy (70% of available votes).ConclusionPCPs face challenges getting their patients to re-initiate statins, particularly after a patient reports side effects.
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Project description:BackgroundIn 2014, Indonesia launched a mandatory national health insurance system called Jaminan Kesehatan Nasional (JKN). The reform introduced new conditions for primary care physicians (PCPs) that could influence their job satisfaction. This study assessed PCPs' satisfaction and its predictors in two cities in Central Java, Indonesia, following the reform.MethodsIn this exploratory, cross-sectional study, we recruited 276 PCPs from the selected area. The data were all collected in 2016 using self-report questionnaires and interviews. PCPs' satisfaction was measured using a modified version of the Warr-Cook-Wall Job Satisfaction Scale which contains 19 items and uses a Likert-type response scale. Analysis of variance, the Kruskal-Wallis H test, both with Bonferroni corrections for post hoc testing, and Cochran-Mantel-Haenszel tests were used to compare overall job satisfaction between participant groups. We used simple and multiple linear regression analyses to identify the predictors of PCP satisfaction. Furthermore, a logistic regression analysis for binary outcome was applied to model the PCPs intention to leave practice.ResultsPCPs' mean overall satisfaction level was 3.19 out of 5. They tended to be very satisfied with their relationship with colleagues, working hours, and physical working conditions. However, the PCPs were dissatisfied with the new referral system, the JKN health services standards, and JKN policy. The factors significantly associated with job satisfaction (p < 0.001) included type of practice, performance of managerial tasks, and PCPs' perceptions of and experiences with patients. PCP satisfaction was negatively associated (p = 0.004) with PCPs' intention to leave their practice.ConclusionsThe PCPs investigated in these two cities in Central Java had moderate satisfaction after the Indonesian health care reform. PCPs who worked in solo practices, performed managerial tasks, and had good experiences with patients tended to have higher satisfaction scores, which in turn prevented them from developing an intention to leave their practice. The three aspects that PCPs with which most dissatisfied were related with the JKN reform. Because of that, the government and BPJS for Health should aim to improve the JKN system in order to increase PCPs' satisfaction.
| S-EPMC6505224 | biostudies-literature
Project description:BackgroundThe increase in the number of pediatric patients with complex health conditions necessitates the application of advance care planning for children. Earlier, withdrawal of life-sustaining treatment was taboo in the medical society in South Korea due to the history of such practice being punishable by law, and physicians tended to pursue aggressive treatment. With changes in public opinion on end-of-life care, the Korean government enacted a new law that protect human dignity by respecting patients' self-determination and facilitating advance care planning. However, little is known about current state of advance care planning for pediatric patients. The study aimed to assess perceptions regarding advance care planning among South Korean pediatricians and clarify any differences in perception among pediatric subspecialties.MethodsThis study was an observational cross-sectional survey that used a web-based self-report questionnaire. Participants comprised of pediatricians currently caring for children with life-limiting conditions in 2018.ResultsOf the 96 respondents, 89 were included in the analysis. In a hypothetical patient scenario, more hemato-oncologists and intensivists than neonatologists and neurologists preferred to provide comfort care than aggressive treatment. While 72.2% of hemato-oncologists reported that they usually or always discuss advance care plans with parents during treatment, more than half of other pediatricians reported that they seldom do so. Furthermore, 65% of respondents said that they never discuss advance care planning with adolescent patients. Moreover, there were no notable differences among subspecialties. The most prevalent answers to factors impeding advance care planning were lack of systemic support after performing advance care planning (82.0%) and uncertain legal responsibilities (70.8%).ConclusionsThe pediatricians differed in their experiences and attitudes toward advance care planning based on their subspecialty. Consequently, institutional support and education should be provided to physicians so that they can include children and families in discussions on prognosis.
| S-EPMC7500719 | biostudies-literature
Project description:BackgroundPrescription opioid overprescribing is a focal point for legislators, but little is known about opioid prescribing patterns of primary care nurse practitioners (NPs) and physician assistants (PAs).ObjectiveTo identify prescription opioid overprescribers by comparing prescribing patterns of primary care physicians (MDs), nurse practitioners (NPs), and physician assistants (PAs).DesignRetrospective, cross-sectional analysis of Medicare Part D enrollee prescription data.ParticipantsTwenty percent national sample of 2015 Medicare Part D enrollees.Main measuresWe identified potential opioid overprescribing as providers who met at least one of the following: (1) prescribed any opioid to > 50% of patients, (2) prescribed ≥ 100 morphine milligram equivalents (MME)/day to > 10% of patients, or (3) prescribed an opioid > 90 days to > 20% of patients.Key resultsAmong 222,689 primary care providers, 3.8% of MDs, 8.0% of NPs, and 9.8% of PAs met at least one definition of overprescribing. 1.3% of MDs, 6.3% of NPs, and 8.8% of PAs prescribed an opioid to at least 50% of patients. NPs/PAs practicing in states with independent prescription authority were > 20 times more likely to overprescribe opioids than NPs/PAs in prescription-restricted states.ConclusionsMost NPs/PAs prescribed opioids in a pattern similar to MDs, but NPs/PAs had more outliers who prescribed high-frequency, high-dose opioids than did MDs. Efforts to reduce opioid overprescribing should include targeted provider education, risk stratification, and state legislation.
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Project description:Pulmonary arterial hypertension (PAH) is a chronic, symptomatic, life-threatening illness; however, it is complex, with variable expression regarding impact on quality of life (QOL). This study investigated attitudes and comfort of physicians regarding palliative care (PC) for patients with PAH and explored potential barriers to PC in PAH. An internet-based, mixed-methods survey was distributed to Pulmonary Hypertension Clinicians and Researchers, a professional organization within the Pulmonary Hypertension Association. Only responses from physicians involved in clinical care of patients with PAH were analyzed. Of 355 clinicians/researchers, 79 (22%) returned surveys, including 76 (21%) providers involved in clinical care. Responding physicians were mainly pulmonologists (67%), practiced in university/academic medical centers (89%), had been in practice a mean of 12 ± 7 years, cared for a median of 100 PAH patients per year, and reported a high level of confidence in managing PAH (87%), advanced PAH-specific pharmacologic interventions (95%), and end-of-life care (88%). Smaller proportions were comfortable managing pain (62%) and QOL issues (78%). Most physicians (91%) reported utilizing PC consultation at least once in the prior year, primarily in the setting of end-of-life/active dying (59%), hospice referral (46%), or symptomatic dyspnea/impaired QOL (40%). The most frequent reasons for not referring patients to PC included nonapproval by the patient/family (51%) and concern that PC is "giving up hope" (43%). PAH may result in symptoms that impair QOL despite optimal PAH therapy; however, PC awareness and utilization for PAH providers is low. Opportunities may exist to integrate PC into care for PAH patients.
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