Team dynamics, clinical work satisfaction, and patient care coordination between primary care providers: A mixed methods study.

BACKGROUND: Team-based care is essential for delivering high-quality, comprehensive, and coordinated care. Despite considerable research about the effects of team-based care on patient outcomes, few studies have examined how team dynamics relate to provider outcomes. PURPOSE: The aim of this study was to examine relationships among team dynamics, primary care provider (PCP) clinical work satisfaction, and patient care coordination between PCPs in 18 Harvard-affiliated primary care practices participating in Harvard's Academic Innovations Collaborative. METHODOLOGY: First, we administered a cross-sectional survey to all 548 PCPs (267 attending clinicians, 281 resident physicians) working at participating practices; 65% responded. We assessed the relationship of team dynamics with PCPs' clinical work satisfaction and perception of patient care coordination between PCPs, respectively, and the potential mediating effect of patient care coordination on the relationship between team dynamics and work satisfaction. In addition, we embedded a qualitative evaluation within the quantitative evaluation to achieve a convergent mixed methods design to help us better understand our findings and illuminate relationships among key variables. FINDINGS: Better team dynamics were positively associated with clinical work satisfaction and quality of patient care coordination between PCPs. Coordination partially mediated the relationship between team dynamics and satisfaction for attending clinicians, suggesting that higher satisfaction depends, in part, on better teamwork, yielding more coordinated patient care. We found no mediating effects for resident physicians. Qualitative results suggest that sources of satisfaction from positive team dynamics for PCPs may be most relevant to attending clinicians. PRACTICE IMPLICATIONS: Improving primary care team dynamics could improve clinical work satisfaction among PCPs and patient care coordination between PCPs. In addition to improving outcomes that directly concern health care providers, efforts to improve aspects of team dynamics may also help resolve critical challenges in workforce planning in primary care.

Design of a cluster-randomized trial of electronic health record-based tools to address overweight and obesity in primary care.

BACKGROUND: Primary care providers often fail to identify patients who are overweight or obese or discuss weight management with them. Electronic health record-based tools may help providers with the assessment and management of overweight and obesity. PURPOSE: We describe the design of a trial to examine the effectiveness of electronic health record-based tools for the assessment and management of overweight and obesity among adult primary care patients, as well as the challenges we encountered. METHODS: We developed several new features within the electronic health record used by primary care practices affiliated with Brigham and Women's Hospital in Boston, MA. These features included (1) reminders to measure height and weight, (2) an alert asking providers to add overweight or obesity to the problem list, (3) reminders with tailored management recommendations, and (4) a Weight Management screen. We then conducted a pragmatic, cluster-randomized controlled trial in 12 primary care practices. RESULTS: We randomized 23 clinical teams ("clinics") within the practices to the intervention group (n = 11) or the control group (n = 12). The new features were activated only for clinics in the intervention group. The intervention was implemented in two phases: the height and weight reminders went live on 15 December 2011 (Phase 1), and all of the other features went live on 11 June 2012 (Phase 2). Study enrollment went from December 2011 through December 2012, and follow-up ended in December 2013. The primary outcomes were 6-month and 12-month weight change among adult patients with body mass index ≥25 who had a visit at one of the primary care clinics during Phase 2. Secondary outcome measures included the proportion of patients with a recorded body mass index in the electronic health record, the proportion of patients with body mass index ≥25 who had a diagnosis of overweight or obesity on the electronic health record problem list, and the proportion of patients with body mass index ≥25 who had a follow-up appointment about their weight or were prescribed weight loss medication. LESSONS LEARNED: We encountered challenges in our development of an intervention within the existing structure of an electronic health record. For example, although we decided to randomize clinics within primary care practices, this decision may have introduced contamination and led to some imbalance of patient characteristics between the intervention and control practices. Using the electronic health record as the primary data source reduced the cost of the study, but not all desired data were recorded for every participant. CONCLUSION: Despite the challenges, this study should provide valuable information about the effectiveness of electronic health record-based tools for addressing overweight and obesity in primary care.

The "medical neighborhood": integrating primary and specialty care for ambulatory patients.

As health care organizations create larger networks, better coordination of primary and specialty care is paramount. Attention has focused on strengthening primary care by creating patient-centered medical homes. The "medical neighborhood" provides a framework for structured, reciprocal relationships that integrate specialty care and extend the principles of the medical home to all practicing physicians. The foundation of the medical neighborhood is the collaborative care agreement, which outlines mutual expectations for primary care physicians and specialists as they care for patients together. These expectations include a preconsultation exchange between the referring physician and the consultant, the consultation, and subsequent comanagement of patients over time. Although independent practices can create individualized collaborative care agreements with specific specialist colleagues, large health care provider networks and accountable care organizations should have 1 agreement for all affiliated physicians. Challenges to the medical neighborhood include fee-for-service reimbursement, existing referral relationships, and building a robust electronic platform, including a referral management module. Cooperation between physicians, regardless of their specialty, and innovation in payment models and electronic platforms will all be essential if medical neighborhoods are to succeed.

Disparities among the disadvantaged: variation in lipid management in the Ohio Medicaid program.

BACKGROUND: Racial disparities exist in cardiovascular disease (CVD) prevention, but other non-clinical factors may influence treatment, further exacerbating disparities. METHODS: Using Ohio Medicaid data from 1992 to 1999, we identified a sample of 19,106 individuals with CVD-related diagnoses or procedures. A review of pharmacy claims identified previous, new, and long-term users of lipid-lowering agents, including statins, fibrates, and bile sequestrants. RESULTS: 3,934 (20.6%) Medicaid beneficiaries used lipid-lowering medications previously, 1,598 (10.5%) filed new claims, and 2,998 of 5,532 (54.2%) previous or new users filed >or=6 claims for refills. Minority adults

Physicians' attitudes and preventive care delivery: insights from the DOPC study.

BACKGROUND: Interventions that modify physician attitudes to enhance preventive service delivery are common, yet other factors may be relatively more important in determining whether these services are provided. We assessed associations between physicians' attitudes and delivery of preventive care, compared with factors related to the patient, visit, or practice. METHODS: One hundred twenty-eight primary care physicians rated the importance of five preventive services and their effectiveness at delivering them. We assessed whether their patients had received cervical smears, prostate-specific antigen (PSA) testing, smoking cessation advice, recommendation to use aspirin to prevent myocardial infarction, or weight-maintenance counseling, when appropriate. Multilevel models assessed associations between physician attitudinal characteristics and a patient's likelihood of being up to date for each service. RESULTS: Importance of PSA screening and tobacco cessation counseling were weakly associated with patients' receipt of preventive care; no association between attitudes and other services was observed. Factors such as having a visit for well care and use of prevention flowcharts were associated with delivery of preventive services to a greater extent. CONCLUSIONS: Physicians' attitudes toward prevention are necessary, but not sufficient in ensuring the delivery of preventive services. Future interventions should address visit- and practice-specific factors more closely associated with preventive care.

Impact of nonprescriptive factors on low-density lipoprotein cholesterol reduction with statins.

Nonprescriptive factors, including patient adherence, can affect the fluctuations in low-density lipoprotein (LDL) cholesterol observed in the clinical setting. In 241 statin-treated patients, although drugs and doses remained fixed, 57% of patients initially successful in reaching LDL cholesterol targets showed subsequent increases in LDL cholesterol. Conversely, 60% of patients who initially failed to reach targets had subsequent reductions in LDL cholesterol, with nearly 1/3 eventually attaining their LDL cholesterol goals.

Frequent ventricular ectopy after exercise as a predictor of death.

BACKGROUND: Exercise-induced ventricular ectopy predicts an increased risk of death in population-based cohorts. We sought to examine in a clinical cohort the prognostic importance of ventricular ectopy immediately after exercise, when reactivation of parasympathetic activity occurs. We hypothesized that ventricular ectopy after exercise (i.e., during the recovery phase) would predict an increased risk of death better than ventricular ectopy during exercise. METHODS: We studied 29,244 patients (mean [+/-SD] age, 56+/-11 years; 70 percent men) who had been referred for symptom-limited exercise testing without a history of heart failure, valve disease, or arrhythmia. Frequent ventricular ectopy was defined by the presence of seven or more ventricular premature beats per minute, ventricular bigeminy or trigeminy, ventricular couplets or triplets, ventricular tachycardia, ventricular flutter, torsade de pointes, or ventricular fibrillation. RESULTS: Frequent ventricular ectopy occurred only during exercise in 945 patients (3 percent), only during recovery in 589 (2 percent), and during both exercise and recovery in 491 (2 percent). There were 1862 deaths during a mean of 5.3 years of follow-up. Frequent ventricular ectopy during exercise predicted an increased risk of death (five-year death rate, 9 percent, vs. 5 percent among patients without frequent ventricular ectopy during exercise; hazard ratio, 1.8; 95 percent confidence interval, 1.5 to 2.1; P<0.001), but frequent ventricular ectopy during recovery was a stronger predictor (11 percent vs. 5 percent; hazard ratio, 2.4; 95 percent confidence interval, 2.0 to 2.9; P<0.001). After propensity matching for confounding variables, frequent ventricular ectopy during recovery predicted an increased risk of death (adjusted hazard ratio, 1.5; 95 percent confidence interval, 1.1 to 1.9; P=0.003), but frequent ventricular ectopy during exercise did not (adjusted hazard ratio, 1.1; 95 percent confidence interval, 0.9 to 1.3; P=0.53). CONCLUSIONS: Frequent ventricular ectopy during recovery after exercise is a better predictor of an increased risk of death than ventricular ectopy occurring only during exercise.

Statins do not meet expectations for lowering low-density lipoprotein cholesterol levels when used in clinical practice.

BACKGROUND: Statins have become a mainstay in the treatment of hyperlipidemia, based on their potency and favorable side-effect profile. Drug choice is presumed to be guided by the estimated degree of low-density lipoprotein (LDL) cholesterol lowering required in a particular patient and the projected efficacy of any drug-dose combination, as contained in the package inserts for each medication. We investigated whether these expectations were met in a clinical practice. METHODS: Data were analyzed for 367 hyperlipidemic patients in a preventive cardiology practice who were not taking statins at entry, who were given a standard statin dose at their first visit, and who had at least one follow-up visit on the same drug/dose. Expected LDL cholesterol reductions were calculated for each patient based on guidelines in the package inserts for each drug. RESULTS: The mean (+/-SD) observed LDL cholesterol reduction of 26% +/- 20% was significantly less than expected (34% +/- 7%, P < 0.001). The ratio of observed to expected reduction was not different for the three statins used (atorvastatin, 0.79 +/- 0.48; simvastatin, 0.88 +/- 0.61; pravastatin, 0.75 +/- 0.69; P = 0.39). CONCLUSIONS: The use of statins in a clinical practice led to observed reductions in LDL cholesterol level that were significantly less than those projected by package insert guidelines. We believe this gap reflects the reduced patient compliance frequently observed in clinical practice settings, rather than any inherent difference in statin responsiveness of a practice versus a trial population. Physicians should be aware of this disparity when using statins in the clinical setting.