Pediatric Acute Q Fever in Rural Wisconsin: A Case Report.

INTRODUCTION: Q fever is a zoonotic disease with a variable clinical presentation and potentially fatal complications. While rare, it is more common in rural areas due to its transmission from animals, including cattle. CASE PRESENTATION: A 3-year-old boy presented in December 2020 with intermittent fevers, headache, rash, and lymphadenopathy. After several months of symptoms, he was diagnosed with acute Q fever. DISCUSSION: This case demonstrates the importance of considering Q fever in the differential diagnosis when a patient presents with nonspecific infectious symptoms and an epidemiological link that places them at risk. CONCLUSIONS: While rare, Q fever is a potentially serious infection that can affect people living in Wisconsin's rural farming communities.

Primary Care Patients' and Staff's Perceptions of Self-Rooming as Alternative to Waiting Rooms.

PURPOSE: Most patients are escorted to exam rooms (escorted rooming) although patients directing themselves to their exam room (self-rooming) saves patient and staff time while increasing patient satisfaction. This study assesses patient and staff perceptions after pragmatic implementation of self-rooming. METHODS: In October-December 2020, we surveyed patients and staff in 25 primary care clinics after our institution expanded self-rooming from 4 specially built clinics during the COVID-19 pandemic. Semi-structured surveys asked about rooming process used, rooming process preferred, and perceptions of self-rooming compared with escorted rooming. RESULTS: Most patients (n = 1,561) preferred self-rooming (86%), especially among patients aged <65 years and in family medicine clinics. Few patients felt less welcomed (10.6%), less cared about (6.8%), more isolated (15.6%), more lost/confused (7.6%), or more frustrated (3.2%) with self-rooming compared with escorted rooming. Early-adopter clinics that implemented self-rooming ≤2016 had even lower rates of patients feeling more isolated, lost/confused, or frustrated with self-rooming compared with escorted rooming.Over one-half of staff (n = 241; 180 clinical, 61 nonclinical) preferred self-rooming (59%) and thought most patients liked self-rooming (65.8%), especially among clinical staff and in early adopter clinics (≤2016). Few staff reported worse waiting times for patients (12.4%), medical assistants (MAs) (15.9%), and clinicians (16.4%) or worse crowding in waiting areas (1.7%) and hallways (10.1%). Unlike patient-reported confusion (7.6%), most staff thought self-rooming led to more patient confusion (63.8%), except in early-adopter clinics (44.4%). CONCLUSIONS: Self-rooming is a patient-centered innovation that is also acceptable to staff. We demonstrated that pragmatic implementation is feasible across primary care without expensive technology or specially designed buildings.

Collaborative care implementation: lessons learned.

The authors drafted a "Shared Values of Collaborative Care" document with fundamental principles to make better group decisions in implementing collaborative care.

Reduction in Medication Refill Encounters Through Primary Care Redesign Workflow Changes.

With a goal of improving efficiency and reducing workload outside of visits, we sought to examine a primary care redesign process aimed at reducing refill requests made outside of office visits. Data on the number of refill encounters per panel member were collected at 17 clinics before, during, and after the implementation of a redesign process. There was an initial reduction in the number of medication refill encounters, and the rate of refill encounters continued to decline following implementation. Variation across clinic contexts suggests that redesign processes may need to be tailored for different settings to optimize effectiveness.

Does a Change in Physician Compensation Lead to Changes in Care Delivery in Family Medicine Clinics?

BACKGROUND AND OBJECTIVES: Many highly capitated systems still pay physicians based on relative value units (RVU), which may lead to excessive office visits. We reviewed electronic health records from the family medicine clinic panel members of 97 physicians and 42 residents to determine if a change from RVUs to panel-based compensation influenced care delivery as defined by the number of office visits and telephone contacts per panel member per month. METHODS: A retrospective analysis of the electronic health records of patients seen in 4 residency training clinics, 10 community clinics, and 4 regional clinics was conducted. We assessed face-to-face care delivery and telephone call volume for the clinics individually and for the clinics pooled by clinic type from 1 year before to at least 1 year after the change. RESULTS: Change in physician compensation was not found to have an effect on office visits or telephone calls per panel member per month when pooled by clinic categories. Some significant effects were seen in individual clinics without any clear patterns by clinic size or type. CONCLUSIONS: Change in physician compensation was not a key driver of care delivery in family medicine clinics. Understanding changes in care delivery may require looking at a broad array of system, physician, and patient factors.

Physician Burnout and Timing of Electronic Health Record Use.

Background: Rates of burnout among physicians have been high in recent years. The Electronic Health Record (EHR) is implicated as a major cause of burnout. Objective: To determine the association between physician burnout and timing of EHR use in an academic internal medicine primary care practice. Methods: We conducted an observational cohort study using cross-sectional and retrospective data. Participants included primary care physicians in an academic outpatient general internal medicine practice. Burnout was measured with a single-item question via self-reported survey. EHR time was measured using retrospective automated data routinely captured within the institution's EHR. EHR time was separated into four categories: weekday workhours in-clinic time, weekday workhours out-of-clinic time, weekday afterhours time, and weekend/holiday afterhours time. Ordinal regression was used to determine the relationship between burnout and EHR time categories. Results: EHR use during in-clinic sessions was related to burnout in both bivariate (OR=1.04, 95% CI 1.01, 1.06; p=0.007) and adjusted (OR=1.07, 95% CI 1.03, 1.1; p=0.001) analyses. No significant relationships were found between burnout and afterhours EHR use. Conclusions: In this small single-institution study, physician burnout was associated with higher levels of in-clinic EHR use but not afterhours EHR use. Improved understanding of the variability of in-clinic EHR use, and the EHR tasks that are particularly burdensome to physicians, could help lead to interventions that better integrate EHR demands with clinical care and potentially reduce burnout. Further studies including more participants from diverse clinical settings are needed to further understand the relationship between burnout and afterhours EHR use.

How best to address breast pain in nonbreastfeeding women.

This guide-with accompanying algorithms-will help you to streamline your approach to breast pain in a patient who isn't breastfeeding.

A Simple Framework for Weighting Panels Across Primary Care Disciplines: Findings From a Large US Multidisciplinary Group Practice.

BACKGROUND: Health system redesign necessitates understanding patient population characteristics, yet many primary care physicians are unable to identify patients on their panel. Moreover, accounting for differential workload due to patient variation is challenging. We describe development and application of a utilization-based weighting system accounting for patient complexity using sociodemographic factors within primary care at a large multidisciplinary group practice. METHODS: A retrospective observational study was conducted of 27 clinics across primary care serving more than 150 000 patients. Before and after implementation, we measured empanelment by comparing weighted to unweighted panel size and the number of physicians who could accept patients. Perceived access was measured by the number of patients strongly agreed that an appointment was available when needed. RESULTS: After instituting weighting, the percentage of physicians with open panels decreased for family physicians and pediatricians, but increased for general internists; the number of active patients increased by 2%. One year after implementation, perceived access improved significantly in family and general internal medicine clinics (P < .05). There were no significant changes for general pediatric and adolescent medicine patients. CONCLUSIONS: The creation of a weighing system accounting for complexity resulted in changes in practice closure, increased total patients, and improved access.

Transforming a Family Medicine Residency Into a Community-Oriented Learning Environment.

BACKGROUND AND OBJECTIVES: Improvement in population health has become a key goal of health systems and payers in the United States. Because 80% of health outcomes are driven by social determinants of health beyond medical care and health care access, such improvements require attention to factors outside of the conventional areas of expertise for clinicians. Yet primary care physicians often graduate from training programs with few skills in population and community health. METHODS: In 2011, the University of Wisconsin Department of Family Medicine began transformative work to become a Department of Family Medicine and Community Health (DFMCH). As part of this effort, educators in the department addressed deficiencies in its residency's community and population health curriculum by implementing curricular change and faculty development. A set of guiding principles, "Three Community Health Responsibilities for Family Doctors," was developed to provide background and structure to current and future work. RESULTS: An annual program evaluation survey was administered to faculty and residents between 2012 and 2016. Respondents reported a significant increase in their understanding of population and community health over the prior year in each year this was assessed (P<0.001). CONCLUSIONS: Community and population health principles have become part of the fabric of the entire residency curriculum in the DFMCH. Faculty development was a key part of this work and will be integral to sustaining improvements.

Family Physician Clinical Compensation in an Academic Environment: Moving Away From the Relative Value Unit.

BACKGROUND AND OBJECTIVES: Primary care physician compensation structures have remained largely volume-based, lagging behind changes in reimbursement that increasingly include population approaches such as capitation, bundled payments, and care management fees. We describe a population health-based physician compensation plan developed for two departmental family medicine faculty groups (residency teaching clinic faculty and community clinic faculty) along with outcomes before and after the plan's implementation. METHODS: An observational study was conducted. A pre-post email survey assessed satisfaction with the plan, salary, and salary equity. Physician retention, panel size, and relative value unit (RVU) productivity metrics also were assessed before and after the plan's implementation. RESULTS: Before implementation of the new plan, 18% of residency faculty and 33% of community faculty were satisfied or very satisfied with compensation structure. After implementation, those numbers rose to 47% for residency physicians and 74% for community physicians. Satisfaction with the amount of compensation also rose from 33% to 68% for residency faculty and from 26% to 87% for community faculty. For both groups, panel size per clinical full-time equivalent increased, and RVUs moved closer to national benchmarks. RVUs decreased for residency faculty and increased for community faculty. CONCLUSIONS: Aligning a compensation plan with population health delivery by moving rewards away from RVU productivity and toward panel management resulted in improved physician satisfaction and retention, as well as larger panel sizes. RVU changes were less predictable. Physician compensation is an important component of care model redesign that emphasizes population health.

"A Paradox Persists When the Paradigm Is Wrong": Pisacano Scholars' Reflections from the Inaugural Starfield Summit.

The inaugural Starfield Summit was hosted in April 2016 by the Robert Graham Center for Policy Studies in Family Medicine and Primary Care with additional partners and sponsors, including the Pisacano Leadership Foundation (PLF). The Summit addressed critical topics in primary care and health care delivery, including payment, measurement, and team-based care. Invited participants included an interdisciplinary group of pediatricians, family physicians, internists, behaviorists, trainees, researchers, and advocates. Among the family physicians invited were both current and past PLF (Pisacano) scholars. After the Summit, a small group of current and past Pisacano scholars formed a writing group to reflect on and summarize key lessons and conclusions from the Summit. A Summit participant's statement, "a paradox persists when the paradigm is wrong," became a repeated theme regarding the paradox of primary care within the context of the health care system in the United States. The Summit energized participants to renew their commitment to Dr. Starfield's 4 C's of Primary Care (first contact access, continuity, comprehensiveness, and care coordination) and to the Quadruple Aim (quality, value, and patient and physician satisfaction) and to continue to explore how primary care can best shape the future of the nation's health care system.

What is the best surveillance for hepatocellular carcinoma in chronic carriers of hepatitis B?

Screening patients with chronic hepatitis B infection (HBsAg+) for hepatocellular carcinoma by alpha-fetoprotein (AFP) or by AFP plus ultrasound (AFP/US) detects hepatocellular carcinoma tumors at earlier stages and increases resection rates (strength of recommendation [SOR]: B, based on a systematic review of fair-quality randomized controlled trials). It is unclear whether screening with AFP or AFP/US improves disease-specific or all-cause mortality (SOR: B).

Interpersonal continuity of care and care outcomes: a critical review.

PURPOSE: We wanted to undertake a critical review of the medical literature regarding the relationships between interpersonal continuity of care and the outcomes and cost of health care. METHODS: A search of the MEDLINE database from 1966 through April 2002 was conducted by the primary author to find original English language articles focusing on interpersonal continuity of patient care. The articles were then screened to select those articles focusing on the relationship between interpersonal continuity and the outcome or cost of care. These articles were systematically reviewed and analyzed by both authors for study method, measurement technique, and quality of evidence. RESULTS: Forty-one research articles reporting the results of 40 studies were identified that addressed the relationship between interpersonal continuity and care outcome. A total of 81 separate care outcomes were reported in these articles. Fifty-one outcomes were significantly improved and only 2 were significantly worse in association with interpersonal continuity. Twenty-two articles reported the results of 20 studies of the relationship between interpersonal continuity and cost. These studies reported significantly lower cost or utilization for 35 of 41 cost variables in association with interpersonal continuity. CONCLUSIONS: Although the available literature reflects persistent methodologic problems, it is likely that a significant association exists between interpersonal continuity and improved preventive care and reduced hospitalization. Future research in this area should address more specific and measurable outcomes and more direct costs and should seek to define and measure interpersonal continuity more explicitly.