Outcomes that Matter: High-Needs Patients' and Primary Care Leaders' Perspectives on an Intensive Primary Care Pilot.

BACKGROUND: Quantitative evaluations of the effectiveness of intensive primary care (IPC) programs for high-needs patients have yielded mixed results for improving healthcare utilization, cost, and mortality. However, IPC programs may provide other value. OBJECTIVE: To understand the perspectives of high-needs patients and primary care facility leaders on the effects of a Veterans Affairs (VA) IPC program on patients. DESIGN: A total of 66 semi-structured telephone interviews with high-needs VA patients and primary care facility leaders were conducted as part of the IPC program evaluation. PARTICIPANTS: High-needs patients (n = 51) and primary care facility leaders (n = 15) at 5 VA pilot sites. APPROACH: We used content analysis to examine interview transcripts for both a priori and emergent themes about perceived IPC program effects. KEY RESULTS: Patients enrolled in VA IPCs reported improvements in their experience of VA care (e.g., patient-provider relationship, access to their team). Both patients and leaders reported improvements in patient motivation to engage with self-care and with their IPC team, and behaviors, especially diet, exercise, and medication management. Patients also perceived improvements in health and described receiving assistance with social needs. Despite this, patients and leaders also outlined patient health characteristics and contextual factors (e.g., chronic health conditions, housing insecurity) that may have limited the effectiveness of the program on healthcare cost and utilization. CONCLUSIONS: Patients and primary care facility leaders report benefits for high-needs patients from IPC interventions that translated into perceived improvements in healthcare, health behaviors, and physical and mental health status. Most program evaluations focus on cost and utilization, which may be less amenable to change given this cohort's numerous comorbid health conditions and complex social circumstances. Future IPC program evaluations should additionally examine IPC's effects on quality of care, patient satisfaction, quality of life, and patient health behaviors other than utilization (e.g., engagement, self-efficacy).

The diagnosis of anger as a presenting complaint in outpatient medical settings.

OBJECTIVE: This study examined the diagnostic patterns for individuals presenting with a complaint of anger. METHODS: The study examined the rates of psychiatric diagnoses in a nationally representative sample of visits (N=1,005,628) to outpatient medical settings by adults who presented with a complaint of anger. Data were from the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey from 1998-2008. RESULTS: Anger accounted for .14% (N=1,146) of the presenting complaints among all adults and was associated with being uninsured, Medicaid enrollment, Caucasian race, male gender, and younger age. Eighty-four percent of visits with an anger complaint included a psychiatric diagnosis, with 44% of diagnoses characterized as "not otherwise specified." CONCLUSIONS: Individuals who presented with a complaint of anger received a range of conventional mental health diagnoses. These findings suggested a pattern of diagnosis of a presenting complaint of anger that may encourage inadequate or improper treatment.