Practice Infrastructure & Quality

What is quality care? It is the right care at the right time for a patient, which requires obtaining the right balance of care for patients as individual -- making sure patients are being subjected to the right tests, but not subjecting them to an overabundance of testing that is outside of the scope of their current ailments. The Graham Center is committed to research that will promote policy-level changes that can improve the quality of health care in the US.

The Robert Graham Center’s research on practice infrastructure bolsters the body of research surrounding Patient Centered Medical Homes (PCMH). Key infrastructure elements ranging from factors leading physicians to adopt electronic health records to the services associated with blended payment models and care management fees are closely examined.

Narrow Results:

  • Primary Care Physician Characteristics Associated with Prescribing Potentially Inappropriate Medication for Elderly Patients: Medicare Part D Data

    Articles | Sep 16, 2020 | Avanthi Jayaweera, MD; Yoonkyung Chung, PhD; and Yalda Jabbarpour, MD

    Despite the high risk of adverse drug events associated with potentially inappropriate medications (PIMs), primary care physicians (PCPs) continue to prescribe them for the elderly. The objective of this study was to explore PIM prescribing behavior in relation to characteristics among PCPs practicing in the United States.

  • Impact of Health Information Technology Optimization on Clinical Quality Performance in Health Centers: A National Cross-Sectional Study

    Articles | Aug 26, 2020 | Robert Baillieu, MD; Hank Hoang, PharmD, MS; Alek Sripipatana, PhD, MPH; Suma Nair, PhD, MS; and Sue C. Lin, PhD, MS

    This study examines the association between health center organization’s health information technology (IT) optimization and clinical quality performance.

  • Accountable Care Organizations Serving Deprived Communities Are Less Likely to Share in Savings

    Articles | Nov 15, 2019 | Alex R. Webb, MD; Winston Liaw, MD, MPH; YoonKyung Chung, PhD; Stephen Petterson, PhD; and Andrew Bazemore, MPH, MD

    Primary care physicians are increasingly participating in ACOs. While prior studies have identified ACO and patient characteristics associated with savings, none have examined characteristics of the communities served by ACOs. Our objective was to assess the relationship between an ACO's service area characteristics and its savings rate.

  • Comparing Comprehensiveness in Primary Care Specialties and Their Effects on Healthcare Costs and Hospitalizations in Medicare Beneficiaries

    Articles | Sep 13, 2019 | Tracey L. Henry MD MPH MS; Russell S. Phillips MD; Robert L. Phillips Jr. MD MSPH; Stephen Petterson, PhD; and Andrew Bazemore, MPH, MD

    Comparing Comprehensiveness in Primary Care Specialties

  • Primary Care Physician Characteristics Associated with Low Value Care Spending

    Articles | Mar 15, 2019 | Tyler W. Barreto, MD; Yoonkyung Chung, PhD; Peter Wingrove, BS; Stephen Petterson, PhD; Richard A. Young, MD; Andrew Bazemore, MPH, MD; and Winston Liaw, MPH, MD

    Little is known about the association between primary care physician characteristics and low value care spending. We performed a retrospective analysis by using Medicare claims data to identify LVC and American Medical Association Masterfile data for PCP characteristics.

  • Higher Primary Care Physician Continuity is Associated With Lower Costs and Hospitalizations

    Articles | Nov 28, 2018 | Stephen Petterson, PhD; Lars E. Peterson, MD, PhD; Richard Bruno, MD, MPH; Yoonkyung Chung, PhD; Robert L. Phillips Jr, MD, MSPH; and Andrew Bazemore, MD, MPH

    Continuity of care is a defining characteristic of primary care associated with lower costs and improved health equity and care quality. However, we lack provider-level measures of primary care continuity amenable to value-based payment, including the Medicare Quality Payment Program (QPP). We created 4 physician-level, claims-based continuity measures and tested their associations with health care expenditures and hospitalizations.

  • Core Principles to Improve Primary Care Quality Management

    Articles | Nov 12, 2018 | Justin B. Mutter, MD, MSc; Winston Liaw, MD, MPH; Miranda A. Moore, PhD; Rebecca S. Etz, PhD; Amanda Howe, MD, MEd, FRCGP; and Andrew Bazemore, MD, MPH

    Quality management in American health care is in crisis. Performance measurement in its current form is costly, redundant, and labyrinthine.

  • Core Principles to Improve Primary Care Quality Management

    Articles | Nov 12, 2018 | Justin B. Mutter, MD, MSc; Winston Liaw, MD, MPH; Miranda A. Moore, PhD; Rebecca S. Etz, PhD; Amanda Howe, MD, MEd, FRCGP; and Andrew Bazemore, MD, MPH

    Quality management in American health care is in crisis. Performance measurement in its current form is costly, redundant, and labyrinthine.

  • The Growing Trend of Health Coaches in Team-Based Primary Care Training

    Articles | Jul 10, 2018 | Nicole M. Gastala, MD; Peter M. Wingrove, BS; Anne H. Gaglioti, MD; Winston Liaw, MD, MPH; and Andrew Bazemore, MD, MPH

    Team-based care with health coaches has improved the quality and cost effectiveness of chronic disease management and prevention. Clinical health coaches partner with patients to identify health goals, create action plans, overcome barriers to change, reinforce physician recommendations, and coordinate care. It is important to train resident physicians to practice in team-based settings.

  • Advancing the Science of Implementation in Primary Health Care

    Articles | May 09, 2018 | Andrew W. Bazemore, MD, MPH

    Implementation Science is commonly described as the study of methods and approaches that promote the uptake and use of evidence-based interventions into routine practice and policymaking.

  • Improving the Quality of Primary Care by Optimizing Implementation Research Reporting

    Articles | May 09, 2018 | Andrew W. Bazemore, MD, MPH

    The potential of implementation research in understanding strategies for changing practice is undermined by poor reporting, leaving readers unable to replicate such strategies and unclear whether they apply in the context of their practice. These challenges are particularly pertinent in the complex, diverse world of primary care.

  • Community Health Workers Bring Cost Savings to Patient-Centered Medical Homes

    Articles | Jan 29, 2018 | Maurice L. Moffett; Arthur Kaufman; and Andrew Bazemore, MD, MPH

    The PCMH has been widely promoted and recognized as a model for achieving effectiveness, equity and efficiency of care. However, the model demonstrates only a modest cost savings. Would addressing SDH increase cost savings?

  • Using Drug Prescribing Patterns to Identify Stewards of Cost-Conscious Care

    Articles | Jan 09, 2018 | Nicole Michele Gastala, MD; Peter Wingrove, BS; Winston Liaw, MD, MPH; Stephen Petterson, PhD; and Andrew Bazemore, MD, MPH

    To characterize family physicians (FPs) who are stewards of care by consistently prescribing omeprazole over esomeprazole.

  • The Impact of Primary Care Practice Transformation on Cost, Quality, and Utilization40 page PDF

    Reports | Aug 01, 2017 | Yalda Jabbarpour, MD; Emilia DeMarchis, MD; Andrew Bazemore, MD, MPH; Paul Grundy, MD, MPH

    The Impact of Primary Care Practice Transformation on Cost, Quality, and Utilization report reviews PCMH results from 45 peer-reviewed reports and additional government and state evaluations in 2016. Implementation of the PCMH and high performing primary care differs depending upon the needs and preferences of those delivering, receiving, and paying for related care.

  • Community Health Workers Bring Cost Savings to Patient-Centered Medical Homes

    Articles | Jul 31, 2017 | Maurice L. Moffett; Arthur Kaufman; and Andrew Bazemore, MD, MPH

    The Patient-Centered Medical Home (PCMH) model demonstrated that processes of care can be improved while unnecessary care, such as preventable emergency department utilization, can be reduced through better care coordination. A complementary model, the Integrated Primary Care and Community Support (I-PaCS) model, which integrates community health workers (CHWs) into primary care settings, functions beyond improved coordination of primary medical care to include management of the social determinants of health.

  • Bright Spots in Care Management84 page PDF

    Reports | Jun 12, 2017 | Tyler Barreto, MD; Andrew Bazemore, MD, MPH; Megan Coffman, MS; Yalda Jabbarpour, MD; and Winston Liaw, MD, MPH

  • Executive Summary: Bright Spots in Care Management12 page PDF

    Reports | Jun 12, 2017 | Tyler Barreto, MD; Andrew Bazemore, MD, MPH; Megan Coffman, MS; Yalda Jabbarpour, MD; and Winston Liaw, MD, MPH

  • Measures in Primary Care: An Annotated Bibliography11 page PDF

    Reports | Mar 30, 2017 | Yalda Jabbarpour, MD

  • New “Core Quality Measures”: Only a Beginning

    Commentaries & Editorials | Jan 06, 2017 | David Nowels, MD, MPH and Douglas B. Kamerow, MD, MPH

    The Core Quality Measures Collaborative, with input from the AAFP, recently released several groups of reduced core measure sets, including one for primary care

  • Lost in Translation: NIH Funding for Family Medicine Research Remains Limited

    Articles | Sep 15, 2016 | Brianna J. Cameron, MPH; Andrew W. Bazemore, MD, MPH; and Christopher P. Morley, PhD, MA

    Departments of Family Medicine (DFMs) in the United States consistently received around 0.2% of total research funding dollars and 0.3% of all awards awarded by the National Institutes of Health (NIH) across the years 2002 to 2014.

  • Federal Research Funding for Family Medicine: Highly Concentrated, with Decreasing New Investigator Awards

    Articles | Sep 15, 2016 | Brianna J. Cameron, MPH; Andrew W. Bazemore, MD, MPH; and Christopher P. Morley, PhD, MA

    Previous reports have revealed that Family Medicine (FM) as a specialty receives relatively little federal research funding, despite delivering a wide range of care to a diverse set of patients and populations.

  • Family Medicine: An Underutilized Resource in Addressing the Opioid Epidemic?

    One Pagers | Aug 22, 2016 | Jacob Crothers, MD; Stephen Petterson, PhD; Andrew Bazemore, MD, MPH; and Peter Wingrove, BS

    Despite a clear willingness to prescribe opioids, few family physicians (FPs) have the necessary certification to treat opioid use disorder with buprenorphine, an effective, evidence-based treatment.

  • Community Vital Signs: Taking the Pulse of the Community While Caring for Patients

    Articles | Jun 01, 2016 | Lauren S. Hughes, MD, MPH, MSc; Robert L. Phillips Jr., MD, MSPH; Jennifer E. DeVoe, MD, DPhil; and Andrew W. Bazemore, MD, MPH

    Community vital signs—aggregated community-level information about the neighborhoods in which our patients live, learn, work, and play—convey contextual social deprivation and associated chronic disease risks based on where patients live.

  • Supporting Health Reform in Mexico: Experiences and Suggestions From an International Primary Health Care Conference

    Articles | May 16, 2016 | Chris van Weel, MD, PhD; Deborah Turnbull, MPsy, PhD; José Ramirez, MD; Andrew Bazemore, MD, MSHP; Richard H. Glazier, MD; Carlos Jaen, MD, PhD; Bob Phillips, MD, MSHP; and Jon Salsberg, PhD

    A pre-conference at the 2015 Cancun NAPCRG conference aimed to develop an action plan and build leadership

  • Summary: Understanding the Impact of Medicare Advantage on Hopitalization Rates2 page PDF

    Reports | Mar 15, 2016 | The Robert Graham Center

  • Understanding the Impact of Medicare Advantage on Hospitalization Rates: A 12-State Study34 page PDF

    Reports | Mar 15, 2016 | Stephen Petterson, PhD; Andrew Bazemore, MD, MPH; Yalda Jabbarpour, MD; and Peter Wingrove, BS

  • Only 15% of FPs Report Using Telehealth; Training and Lack of Reimbursement Are Top Barriers

    One Pagers | Jan 15, 2016 | Miranda A. Moore, Phd; Megan Coffman, MS; Anuradha Jetty, MPH; Stephen Petterson, PhD; and Andrew Bazemore, MD, MPH

    Little is known about primary care clinicians’ implementation of, awareness of, and attitudes toward telehealth.

  • Solo and Small Practices: A Vital, Diverse Part of Primary Care

    Articles | Jan 11, 2016 | Winston R. Liaw, MD, MPH, Anuradha Jetty, MPH, Stephen M. Petterson, PhD, Lars E. Peterson, MD, PhD and Andrew W. Bazemore, MD, MPH

    Solo and small practices are facing growing pressure to consolidate. This article explores the percentage of family physicians in solo and small practices and the characteristics of and services provided by these practices.

  • Fewer Americans Report a Personal Physician as Their Usual Source of Health Care

    One Pagers | Dec 15, 2015 | Anuradha Jetty, MPH; Larry Green, MD; Andrew Bazemore, MD, MPH; Stephen Petterson, PhD

    One in five Americans reports no usual source of health care, and the number of Americans reporting that they have a personal relationship with a usual source of care has declined steadily over the past 15 years.

  • U.S. Medicare, Medicaid, and Nurse Practitioners all Turn 50

    Commentaries & Editorials | Jul 20, 2015 | Douglas Kamerow, MD

  • More Comprehensive Care Among Family Physicians is Associated with Lower Costs and Fewer Hospitalizations

    Articles | May 11, 2015 | Andrew Bazemore, MD, MPH; Stephen Petterson, PhD; Lars Peterson, MD, PhD; and Robert Phillips, MD, MSPH

    Comprehensiveness is lauded as 1 of the 5 core virtues of primary care, but its relationship with outcomes is unclear. We measured associations between variations in comprehensiveness of practice among family physicians and healthcare utilization and costs for their Medicare beneficiaries.

  • More Comprehensive Care Among Family Physicians is Associated with Lower Costs and Fewer Hospitalization

    Articles | May 01, 2015 | Andrew Bazemore, MD; Robert Phillips, MD, MSPH; Petterson, Stephen, PhD; and Lars Peterson, MD, PhD

    Comprehensiveness is lauded as 1 of the 5 core virtues of primary care, but its relationship with outcomes is unclear. We measured associations between variations in comprehensiveness of practice among family physicians and healthcare utilization and costs for their Medicare beneficiaries.

  • Smaller Practices Are Less Likely to Report PCMH Certification

    One Pagers | Apr 01, 2015 | Melanie Raffoul, MD; Stephen Petterson, PhD; Miranda Moore, PhD; Andrew Bazemore, MD, MPH; and Lars Peterson, MD, PhD

    Despite efforts to achieve broad transformation of primary care practices into patient-centered medical homes (PCMHs), certification rates have lagged in small and solo practices. The challenges these groups face with the transformation and certification processes should be addressed to continue national momentum toward reshaping the nation’s primary care platform.

  • Only One Third of Family Physicians Can Estimate Their Patient Panel Size

    Articles | Mar 16, 2015 | Lars Peterson, MD, PhD; Anneli Cochrane, MPH; Andrew Bazemore, MD, MPH; Elizabeth Baxley, MD; and Robert Phillips, MD, MSPH

    In addition to payments for services rendered to individual patients, primary care physicians will increasingly be paid for their ability to achieve goals across the body of patients most closely associated with them: their “panel.” In a 2013 survey, however, only one third of family physicians could estimate their panel size, raising concern about their ability to perform more advanced primary care functions.

  • Maintenance of Certification, Medicare Quality Reporting, and Qualification of Diabetes Care

    Articles | Mar 02, 2015 | Robert Phillips, MD, MSPH; Brenna Blackburn, MPH; Lars Peterson, MD, PhD; and James Puffer, MD

    Aligning maintenance of certification with quality reporting may ease reporting burden, but the impact on quality is uncertain. This study compared changes in quality measures from American Board of Family Medicine Performance in Practice Modules (PPMs), Physician Quality Reporting System (PQRS), and a combined PQRS/PPM for diabetes between 2008 and 2012.

  • Consideration About Retirement from Clinical Practices by Obstetrician Gynecologist

    Articles | Mar 02, 2015 | Williams Rayburn, MD, MBA; Albert Strunk, JD, MD; and Stephen Petterson, PhD

    Retirement of obstetrician-gynecologists is becoming a matter of increasing concern in light of an expected shortage of practicing physicians. Determining a retirement age is often complex. We address what constitutes a usual retirement age range from general clinical practice for an obstetrician-gynecologist, compare this with practitioners in other specialties, and suggest factors of importance to obstetrician-gynecologists before retirement.

  • Calling All Scholars to Council of Academic Family Medicine Educational Research Alliance (CERA)

    Articles | Mar 02, 2015 | Shokar Navkiran, MD, MPH; GeorgeBergu, MD; Andrew Bazemore, MD, MPH; Randall Clinch, DO, MS; Andrew Coco, MD, MS; Betsy Jones, EdD; Arch Mainous III, PD; Dean Seehusen, MD, MPH; and Vijay Singh, MD, MPH

    The current state of affairs is that as a specialty, we underperform in scholarly and research output compared with our peers in other specialties, and although this has been acknowledged for a while, improvements in research productivity have been slow. Many barriers remain to the generation of research and scholarly output from departments of family medicine.

  • Fewer Family Physicians are in Solo Practices

    Articles | Jan 01, 2015 | Lars Peterson, MD, PhD; Elizabeth Baxley, MD; Carlos Jaen, MD, PhD; and Robert Phillips, MD, MSPH

    Over the past 20 years there has been a statistically significant trend toward fewer family physicians identifying as being in solo practice. Further study to determine the reasons for this decline and its impact on access to care will be critical because rural areas are more dependent on solo practitioners.

  • PAWS for Thought

    Articles | Jan 01, 2015 | Jessica Morgan MD; Elizabeth Day, MD; and Robert Phillips, MD, MSPH

    Pediatric Advanced Warning Scores (PAWS) are scales that are based on clinical observations intended to predict deterioration. We undertook a case-note review of the prevalence of raised PAWS and clinician's responses to these in patients under the care of pediatric hematology and oncology in the Leeds Children's Hospital. We conclude that a raised PAWS does not necessarily indicate significant deterioration, noting that the majority of adverse events occurred in patients without raised PAWS.

  • Trends in Office-Based Care for Reproductive-Aged Women According to Physician Specialty: A Ten-Year Study

    Articles | Dec 23, 2014 | Stephen Petterson, PhD; Andrew Bazemore, MD, MPH; Robert Phillips, MD, MSHP; and William Rayburn, MD

    The anticipated increase in access to health care has prompted an interest in where women go for their office-based care. The objectives of this study were to examine which types of office site are chosen by reproductive-aged women for their health care and to compare the reasons for their visits among these sites.

  • Trends in Physician House Calls to Medicare Beneficiaries

    Articles | Nov 30, 2014 | Lars Peterson, MD, PhD; Stephen Landers, Andrew Bazemore, MD, MPH

    House calls (HCs) to older adults seemed to be headed for extinction in recent decades. HCs may be a tool to ensure access and reduce institutionalization of the elderly population. This study determines the number and distribution of HCs by physician specialty over time and analyzes associations of providing HCs with physician and area-level characteristics.

  • Another Risk to U.S. Travelers—Malaria

    Articles | Nov 10, 2014 | Winston Liaw, MD; Sarah Coleman, MD; Andrew Bazemore, 
MD, MPH; and Mark K. Huntington, MD, PhD

    Although malaria was eradicated as an endemic disease in the United States in the early 1950s,1 it still returns yearly in approximately 1500 individuals who travel to foreign countries2—most of whom neglected to use prophylactic measures or use them properly.3 In more than 60 documented cases, these infected individuals have been the source of local transmission in their communities.2 To reduce the individual and public health risks associated with malaria, this article focuses on steps that international travelers can take to limit their risk of the disease.

  • Cost, Utilization, and Quality of Care: An Evaluation of Illinois’ Medicaid Primary Care Case Management Program

    Articles | Sep 15, 2014 | Robert L. Phillips Jr, MD, MSPH Meiying Han, PhD Stephen M. Petterson, PhD Laura Makaroff, DO Winston R. Liaw, MD, MPH

    In 2006, Illinois established Illinois Health Connect (IHC), a primary care case management program for Medicaid that offered enhanced fee-for-service, capitation payments, performance incentives, and practice support.

  • Do Family Physicians Choose Self-Assessment Activities Based on What They Know or Don't Know?

    Articles | Jun 16, 2014 | Lars E. Peterson MD, PhD*, Brenna Blackburn MPH, Andrew Bazemore MD, MPH, Thomas O'Neill PhD andRobert L. Phillips Jr. MD, MSPH

    Maintenance of Certification (MOC) for Family Physicians (MC-FP) includes clinical Self-Assessment Modules (SAMs). Whether family physicians choose SAMs that reflect their aptitudes or knowledge gaps has not been studied.

  • Mental Health Treatment in the Primary Care Setting: Patterns and Pathways.

    Articles | Jun 09, 2014 | Stephen Petterson, PhD; Benjamin Miller, PsyD; Jessica Payne-Murphy, MA; Robert Phillips, MD, MSPH

    The redesign of primary care through the patient-centered medical home offers an opportunity to assess the role of primary care in treating mental health relative to the rest of the health care system. Better understanding the patterns of care between primary care and mental health providers helps guide necessary policy changes. This article reports the findings from 109,593 respondents to the 2002–2009 Medical Expenditure Panel Surveys (MEPS).

  • Winnable Battles: Family Physicians Play an Essential Role in Addressing Tobacco Use and Obesity

    One Pagers | Jun 05, 2014 | Joseph Nichols MD, MPH and Andrew Bazemore, MD, MPH

    Tobacco use and obesity are linked to most deaths and significant disability in the United States, and family physicians are uniquely positioned to address these issues. This highlights a need for transforming primary care practices and teams to systematize the recognition and management of unhealthy behaviors, and for alternative payment models that support these efforts.

  • Proximity of Providers: Colocating Behavioral Health and Primary Care and the Prospects for an Integrated Workforce

    Articles | May 16, 2014 | Benjamin Miller, PsyD; Stephen Petterson, PhD; Bridget Teevan Burke, MPH; Robert Phillips, MD, MSPH; Larry Green, MD

    Integrated behavioral health and primary care is emerging as a superior means by which to address the needs of the whole person, but we know neither the extent nor the distribution of integration. Using the Centers for Medicare and Medicaid Services’ National Plan and Provider Enumeration System (NPPES) Downloadable File, this study reports where colocation exists for (a) primary care providers and any behavioral health provider and (b) primary care providers and psychologists specifically

  • The Impact of Insurance and a Usual Source of Care on Emergency Department Use in the United States

    Articles | Feb 15, 2014 | Liaw, Winston, MD, MPH; Petterson, Stephen, PhD; Rabin, David L., MPH; and Bazemore, Andrew, MD, MPH

    Finding a usual source of care (USC) is difficult for certain populations. This analysis determines how insurance type and having a USC affect the settings in which patients seek care.

  • Family Physician's Quality Interventions and Performance Improvement Through the ABFM Diabetes Performance in Practice Module

    Articles | Jan 15, 2014 | Lars Peterson, MD, PhD; Brenna Blackburn, MPH; James Puffer, MD; and Robert Phillips, MD, MSPH

    Practice performance assessment is the fourth requirement of Maintenance of Certification for Family Physicians (MC-FP). American Board of Family Medicine (ABFM) diplomates have many options for completing Part 4 requirements, including Web-based Performance in Practice Modules (PPMs) developed by the ABFM. Our objective was to describe the actions and outcomes of family physicians who completed the ABFM diabetes PPM

  • Do Professional Development Programs for Maintenance of Certification (MOC) Affect Quality of Patient Care?

    Articles | Jan 01, 2014 | James M. Galliher, PhD, Brian K. Manning, MPH, Stephen M. Petterson, PhD, L. Miriam Dickinson, PhD, Elias C. Brandt, BS, Elizabeth W. Staton, MSTC, Robert L. Phillips, MD, MSPH and Wilson D. Pace, MD

    The objective of this study was to examine the relationship between physicians' completion of American Board of Family Medicine (ABFM) Maintenance of Certification (MOC) modules and the quality of medical care delivered.

  • Blended Payment Models and Associated Care Management Fees21 page PDF

    Presentations | Nov 07, 2013 | The Robert Graham Center

  • Family Physician Participation in Quality Improvement

    Articles | Nov 01, 2013 | Lars Peterson, MD, PhD; Carlos Jaen, MD, PhD; and Robert Phillips, MD, MSPH

    More than one-third of family physicians reported participating in a quality improvement (QI) activity in the past year. Continuous QI is vital to improving personal and population health outcomes and reducing costs. Support for QI activities, their evaluation, and the dissemination of successful efforts are sorely needed.

  • Relying on NPs and PAs Does Not Avoid the Need for Policy Solutions for Primary Care

    One Pagers | Aug 15, 2013 | Stephen M. Petterson, PhD; Robert L. Phillips, Jr., M.D., MSPH; Andrew W. Bazemore, M.D., MPH; Bridget Teevan Burke, MPH, MS; Gerald T. Koinis, BA

    Physician assistants (PAs) and nurse practitioners (NPs) are often proposed as solutions to the looming shortage of primary care physicians. However, a large and growing number of PAs and NPs now work outside of primary care, which suggests that innovative policy solutions to increase access to primary care are still needed.

  • Family Physicians Are Essential for Mental Health Care Delivery

    Articles | Apr 15, 2013 | Imam M. Xierali, PhD, Sebastian T. Tong, MD, MPH, Stephen M. Petterson, PhD, James C. Puffer, MD, Robert L. Phillips Jr., MD, MSPH and Andrew W. Bazemore, MD, MPH

    As the largest and most widely distributed of primary care physicians, family physicians have an important role in providing mental health care, especially in rural and underserved areas. However, the proportion of family physicians who report providing mental health care is low. Policy barriers such as payment for mental health services should be explored to ensure access to mental health care for patients across the urban to rural continuum.

  • Training a Health Care Workforce to Meet Your State's Needs (and Wants)35 page PDF

    Presentations | Apr 15, 2013 | Andrew Bazemore, MD, MpH

    Training a Health Care Workforce to Meet Your State's Needs (and Wants): Addressing Challenges: Data, Tools and Primary Care

  • The Primary Care Extension Program: A Catalyst for Change

    Articles | Mar 15, 2013 | Phillips RL Jr, Kaufman A, Mold JW, Grumbach K, Vetter-Smith M, Berry A, Burke BT.

    The Affordable Care Act authorized, but did not fund, the Primary Care Extension Program (PCEP). Much like the Cooperative Extension Program of the US Department of Agriculture sped the modernization of farming a century ago, the PCEP could speed the transformation of primary care. It could also help achieve other goals such as integrating primary care with public health and translating research into practice. The urgency of these goals and their importance to achieving the Triple Aim for health care should increase interest in rapidly building the PCEP, much as the need to feed the country did a century ago.

  • Effectiveness Over Efficiency: Underestimating the Primary Care Physicians Shortage

    Articles | Feb 01, 2013 | Robert Phillips, MD, MSPH; Andrew Bazemore, MD, MPH; and Lars Peterson, MD, PhD

    Interest in improving health care outcomes requires increasing the effectiveness of primary care. Focus on effectiveness is leading many innovative health systems to shrink primary care patient panels to strengthen relationships, and to enhance primary care teams to increase comprehensiveness. Such strategies would make primary care shortages worse than predicted, and are compounded by substantial declines in clinicians of all types choosing primary care careers.

  • The Rise of Electronic Health Record Adoption Among Family Physicians

    Articles | Jan 15, 2013 | Xierali IM, Hsiao CJ, Puffer JC, Green LA, Rinaldo JC, Bazemore AW, Burke MT, Phillips RL Jr.

    Realizing the benefits of adopting electronic health records (EHRs) in large measure depends heavily on clinicians and providers' uptake and meaningful use of the technology. This study examines EHR adoption among family physicians using 2 different data sources, compares family physicians with other office-based medical specialists, assesses variation in EHR adoption among family physicians across states, and shows the possibility for data sharing among various medical boards and federal agencies in monitoring and guiding EHR adoption.

  • International Collaboration in Innovating Health Systems

    Articles | Jan 14, 2013 | Chris van Weel, MD, PhD; Deb Turnbull, MPsych, PhD; Emma Whitehead; Andrew Bazemore, MD, MPH; Felicity Goodyear-Smith, MBChB, MD; Claire Jackson, MD; CL Lam; BA van der Linden, D Meyers; M van den Muijsenbergh; Robert Phillips, MD, MSHP; JM Ramirez-Aranda; Robin Tamblyn; and Evelyn van Weel-Baumgarten, MD

    Strong primary health care is critical to secure sustainable health care. The International Implementation Research Network in Primary Care (IIRNPC) was founded to facilitate exchanges of experiences between countries in primary health care implementation. Involvement of all stakeholders, and focus on local conditions to approach health problems in a broad social, economic, political and cultural context are core components.

  • Projecting US Primary Care Physician Workforce Needs: 2010-2025

    Articles | Nov 15, 2012 | Stephen M. Petterson, PhD; Winston R. Liaw, MD, MPH; Robert L. Phillips, Jr, MD, MSPH; David L. Rabin, MD, MPH; David S. Meyers; Andrew W. Bazemore, MD, MPH.

    Researchers project the United States will need 52,000 additional primary care physicians by 2025 — a 25 percent increase in the current workforce — to address the expected increases in demand due to population growth, aging, and insurance expansion following passage of the Affordable Care Act. Analyzing nationally representative data, the researchers conclude population growth will be the single greatest driver of increased primary care utilization, requiring approximately 33,000 additional primary care physicians by 2025, while 10,000 additional physicians will be needed to accommodate population aging. Insurance expansion, they estimate, will require approximately 8,000 additional primary care physicians, a 3 percent increase in the current workforce.

  • Improving America's Health Requires Community-Level Solutions: Folsom Revisited

    One Pagers | Aug 15, 2012 | The American Board of Family Medicine Young Leaders Advisory Group

    Amidst sweeping changes to health care in the 1960s, the broadly influential Folsom Commission report, Health is a Community Affair, never fully achieved its vision of galvanizing the creation of Communities of Solution, which were empowered to improve health at the local level. Passage of health care reform, and persistent concern over poor health outcomes despite runaway spending, contemporizes Folsom’s call for nationally supported and evaluated, but community-driven, solutions to the nation’s health care challenges.

  • Integrating Community Health Centers Into Organized Delivery Systems Can Improve Access to Subspecialty Care

    Articles | Aug 15, 2012 | Katherine Neuhausen, MD; Kevin Grumbach, MD; Andrew Bazemore, MD, MPH; Robert L. Phillips Jr, MD, MSPH

    The Affordable Care Act is funding the expansion of community health centers to increase access to primary care, but this approach will not ensure effective access to subspecialty services. To address this issue, we interviewed directors of twenty community health centers. Our analysis of their responses led us to identify six unique models of how community health centers access subspecialty care, which we called Tin Cup, Hospital Partnership, Buy Your Own Subspecialists, Telehealth, Teaching Community, and Integrated System. We determined that the Integrated System model appears to provide the most comprehensive and cohesive access to subspecialty care. Because Medicaid accountable care organizations encourage integrated delivery of care, they offer a promising policy solution to improve the integration of community health centers into “medical neighborhoods.”

  • Integrating Public Health and Primary Care12 page PDF

    Presentations | May 15, 2012 | Paul Wallace, MD and Sean P. David, MD

    Primary Care and Public Health: Exploring Integration to Improve Population Health

  • Integrating Public Health & Primary Care through Communities of Solution32 page PDF

    Presentations | May 08, 2012 | Sean P. David, M.D., S.M., D.Phil., Andrew Bazemore, M.D., M.P.H., Marguerite R. Duane, M.D., M.H.A., Sarah Lesko, M.D., M.P.H. , Kim S. Griswold, M.D., M.P.H., Thomas M. Morgan, M.D. , John M. Westfall, M.D., M.P.H. , James C. Puffer, M.D. , Larry Green, M.D.

    Integrating Public Health & Primary Care through Communities of Solution

  • EHR Implementation Without Meaningful Use Can Lead to Worse Health Outcomes

    One Pagers | Dec 01, 2011 | Jesse C. Crosson, PhD; Andrew W. Bazemore, MD, MPH; and Robert L. Phillips, Jr., MD, MSPH

    Defying expectations, typical electronic health record (EHR) use in practices belonging to a primary care network has been associated with poorer diabetes care quality and outcomes. Current expansion of primary care EHR implementation must focus on use that improves care.

  • Where the United States Falls Down and How We Might Stand Up

    Commentaries & Editorials | Nov 15, 2011 | Robert L. Phillips, Jr., MD, MSPH

    The Commonwealth Fund and Rand Europe announced this week that the United States ranks last among developed countries in “mortality amenable to health care” — that is, deaths that are considered preventable with timely and effective health care. Preventable death rates declined during the last decade, but the rate of improvement in the United States was slower compared with other countries such that we continue to fall further behind. Compared with other countries, the United States also has much wider disparities in health status and outcomes.

  • Research Productivity of Senior General Practice Academicians in Australia, Canada, England/Wales, New Zealand, Scotland, and the U.S.22 page PDF

    Presentations | Nov 15, 2011 | Susan Dovey, PhD; Andrew W. Bazemore, MD, MPH; Winston Liaw, MD, MPH; Robert L. Phillips, Jr., MD, MSPH

    Research Productivity of Senior General Practice Academicians in Australia, Canada, England/Wales, New Zealand, Scotland, and the U.S.

  • Primary Care Physician Workforce and Outcomes

    Commentaries & Editorials | May 15, 2011 | Robert L. Phillips, Jr; Stephen C. Petterson; and Andrew W. Bazemore.

    Primary Care Physician Workforce and Outcomes

  • Evidence About the Role of the PCMH and ACOs in Improving Quality and Safety36 page PDF

    Presentations | May 15, 2011 | Robert L. Phillips, Jr., MD, MSPH

    Evidence about the Role of the PCMH and ACOs in Improving Quality and Safety

  • Evidence About Your Value (and the Return on Investment)43 page PDF

    Presentations | May 15, 2011 | Robert L. Phillips, Jr., MD, MSPH

    Evidence About Your Value (and the return on investment)

  • Seeking Ethical Approval for an International Study in Primary Care Patient Safety

    Articles | Apr 15, 2011 | S Dovey; K Hall; M Makeham; W Rosser; A Kuzel; C Van Weel; A Esmail; and R Phillips

    Seeking ethics committee approval for research can be challenging even for relatively simple studies occurring in single settings. Complicating factors such as multicentre studies and/or contentious research issues can challenge review processes, and conducting such studies internationally adds a further layer of complexity. This paper draws on the experiences of the LINNAEUS Collaboration, an international group of primary care researchers, in obtaining ethics approval to conduct an international study investigating medical error in general practice in six countries. It describes the ethics review processes applied to exactly the same research protocol for a study run in Australia, Canada, England, the Netherlands, New Zealand, and the U.S. Wide variation in ethics review responses to the research proposal occurred, from no approval being deemed necessary to the study plan narrowly avoiding rejection. The authors' experiences demonstrated that ethics committees operate in their own historical and cultural context, which can lead to radically different subjective interpretations of commonly-held ethical principles, and raised further issues such as 'what is research?'. This first LINNAEUS study started when patient safety was a particularly sensitive subject. Although it is now a respectable area of inquiry, patient safety is still a topic that can excite emotions and prejudices. The LINNAEUS Collaboration now extends to more countries and continues to pursue an international research agenda, so reflection on the influences of history, social context, and structure of each country's ethical review processes is timely.

  • Evidence About the Role of the Patient Centered Medical Home and Accountable Care Organizations in Improving Quality and Safety6 page PDF

    Presentations | Apr 15, 2011 | Robert L. Phillips, Jr., MD, MSPH

    Evidence about the role of the Patient-Centered Medical Home and Accountable Care Organizations in Improving Quality and Safety

  • I LIVE PC: International Learning on Increasing the Value and Effectiveness of Primary Care253 page PDF

    Monographs & Books | Apr 15, 2011 | Robert Graham Center

    View the conference packet from the 2011 International Learning on Increasing the Value and Effectiveness of Primary Care (I LIVE PC) conference, held April 4-5 in Washington, D.C.

  • Case Study of a Primary Care-Based Accountable Care System Approach to Medical Home Transformation

    Articles | Feb 15, 2011 | RL Phillips Jr; S Bronnikov; S Petterson; M Cifuentes; B Teevan; M Dodoo; WD Pace; and DR West

    We report a case study of a mature primary care-based accountable care organization that is both a health plan and a network of medical homes. Over 20 years, WellMed Inc. (San Antonio, Texas) implemented many patient-centered services, experimenting to find which belong within clinics and which operate best as system functions. The adjusted mortality rate is half that of the state for people older than 65 years. Hospitalization and readmission rates and emergency department visits have not changed over time, but preventive services have improved. Phased implementation across the network makes it difficult to link improvements to specific processes but they seem to have improved outcomes collectively.

  • Comparison Between U.S. Preventive Services Task Force Recommendations and Medicare Coverage

    Articles | Jan 15, 2011 | LI Lesser; AH Krist; DB Kamerow; and AW Bazemore

    The U.S. Preventive Services Task Force (USPSTF) is authorized by the U.S. government to review and disseminate the scientific evidence for clinical preventive services. The purpose of this study was to evaluate the alignment of Medicare preventive services coverage with the recommendations of the USPSTF before implementation of health reform. METHODS: We recorded all Medicare coverage for preventive services as listed in the Medicare preventive services guide of 2007 (including the 2009 update) for all recommended (A- or B-rated) USPSTF and not recommended (D-rated) guidelines for preventive screening and counseling in adults aged 65 years and older. We analyzed 2 components of preventive care: preventive coordination (risk assessment, patient motivation, and arranging of preventive service) and the preventive service itself. The main outcome measure was the percentage of agreement between USPSTF recommendations and Medicare coverage. RESULTS: The USPSTF recommended 15 preventive interventions for adults aged 65 years and older. Although Medicare partially reimbursed 93% of recommended services, full reimbursement for the preventive coordination, as well as the service, was available for only 7% of these services. This partial coverage is available mostly as part of the Welcome to Medicare Visit. Further, the USPSTF recommended against 16 preventive services; Medicare reimbursed clinicians for 44% of these services. CONCLUSIONS: Medicare coverage for preventive services needs to be reassessed, with special focus on preventive coordination. Continuing previous practices will likely promote both inadequate and excessive delivery of preventive services. The new health care reform law has the potential to improve the provision of preventive services to Medicare beneficiaries.

  • Primary Care and Health Care Reform43 page PDF

    Presentations | Sep 15, 2010 | Kevin Burke and Andrew Bazemore, MD, MPH

    Primary Care and Health Reform

  • Greater Family Medicine Presence at NIH Could Improve Research Relevance and Reach

    One Pagers | May 15, 2010 | Sean C. Lucan, MD, MPH, MS; Andrew W. Bazemore, MD, MPH; Robert L. Phillips JR., MD, MSPH; Imam Xierali, PhD; Stephen Petterson, PhD; and Bridget Teevan, MS

    Advisory committees perform pivotal tasks at the National Institutes of Health (NIH), informing funding decisions, helping establish research priorities, and contributing to the vision for the nation's biomedical research agenda. Family medicine has not had a substantial role on these committees, but could, helping the NIH make research more patient centered and informing translational efforts to improve population health.

  • Measuring Primary Care Expenses

    Articles | May 15, 2010 | Krist AH; Cifuentes M; Dodoo MS; and Green LA

    BACKGROUND: Significant investments and effort are being devoted to health care reform, yet little is known about the costs of improvements. Practical tools are needed to allow for systematic assessment of practice expenses. We report here a field trial of a standardized expenditure data collection instrument. METHODS: Combining economic and primary care practice consultation, an expenditure data collection instrument was created. The instrument underwent observed feasibility testing and was fielded by 10 practice-based research networks in 30 practices conducting 10 different health behavior change interventions. RESULTS: Start-up and operating expenses were successfully collected for 87% and 97% of the practices, respectively. Data collection time and effort were considerable but acceptable. Three elements were necessary to collect expenditure data: (1) an intervention-specific data collection instrument, (2) a field guide, and (3) economic oversight and assistance. Fully 90% of networks reported that they planned to collect expenditure data in the future and study participation increased the likelihood of their participation in a future expenditure study. CONCLUSIONS: It is feasible to systematically collect intervention-specific expenses in primary care using formal expenditure methods. However, most practices and researchers lack the knowledge, expertise, and resources to collect such data independently. Further assistance and education is necessary to obtain reliable information about the expenses to transform and improve primary care.

  • State Tort Reforms and Hospital Malpractice Costs

    Articles | Mar 15, 2010 | Charles R. Ellington; Martey Dodoo; Robert Phillips; Ronald Szabat; Larry Green; and Kim Bullock

    This study explored the relation between state medical liability reform measures, hospital malpractice costs, and hospital solvency. It suggests that state malpractice caps are desirable but not essential for improved hospital financial solvency or viability.

  • Avertable Deaths Associated with Household Income in Virginia

    Articles | Feb 15, 2010 | SH Woolf, MD, MPH; RM Jones, PhD, MPH; RE Johnson, PhD; RL Phillips Jr, MD, MSPH; MN Oliver, MD; AW Bazemore, MD, MPH; A Vichare, MPH

    Objectives: We estimated how many deaths would be averted if the entire population of Virginia experienced the mortality rates of the 5 most affluent counties or cities. Methods: Using census data and vital statistics for the years 1990 through 2006, we applied the mortality rates of the 5 counties/cities with the highest median household income to the populations of all counties and cities in the state. Results: If the mortality rates of the reference population had applied to the entire state, 24.3% of deaths in Virginia from 1990 through 2006 (range=21.8%–28.1%) would not have occurred. An annual mean of 12954 deaths would have been averted (range=10548–14569), totaling 220211 deaths from 1990 through 2006. In some of the most disadvantaged areas of the state, nearly half of deaths would have been averted. Conclusions: Favorable conditions that exist in areas with high household incomes exert a major influence on mortality rates. The corollary—that health suffers when society is exposed to economic stresses—is especially timely amid the current recession. Further research must clarify the extent to which individual-level factors (e.g., earnings, education, race, health insurance) and community characteristics can improve health outcomes.

  • Harnessing Geographic Information Systems (GIS) to enable Community-Oriented Primary Care

    Articles | Jan 15, 2010 | Andrew Bazemore, MD, MPH; Robert L. Phillips, MD, MSPH, FAAFP; and Thomas Miyoshi, MSW

    Background: Despite growing acceptance and implementation of geographic information systems (GIS) in the public health arena, its utility for clinical population management and coordination by leaders in a primary care clinical health setting has been neither fully realized nor evaluated. Methods: In a primary care network of clinics charged with caring for vulnerable urban communities, we used GIS to (1) integrate and analyze clinical (practice management) data and population (census) data and (2) generate distribution, service area, and population penetration maps of those clinics. We then conducted qualitative evaluation of the responses of primary care clinic leaders, administrators, and community board members to analytic mapping of their clinic and regional population data. Results: Practice management data were extracted, geocoded, and mapped to reveal variation between actual clinical service areas and the medically underserved areas for which these clinics received funding, which was surprising to center leaders. In addition, population penetration analyses were performed to depict patterns of utilization. Qualitative assessments of staff response to the process of mapping clinical and population data revealed enthusiastic engagement in the process, which led to enhanced community comprehension, new ideas about data use, and an array of applications to improve their clinical revenue. However, they also revealed barriers to further adoption, including time, expense, and technical expertise, which could limit the use of GIS and mapping unless economies of scale across clinics, the use of web technology, and the availability of dynamic mapping tools could be realized. Conclusions: Analytic mapping was enthusiastically received and practically applied in the primary care setting, and was readily comprehended by clinic leaders for innovative purposes. This is a tool of particular relevance amid primary care safety-net expansion and increased funding of health information technology diffusion in these settings, particularly if the hurdles of cost and technological expertise are overcome by harnessing new advances in web-based mapping technology.

  • Improving the Delivery of Preventive Services to Medicare eneficiaries

    Commentaries & Editorials | Dec 23, 2009 | Lenard I. Lesser, MD and Andrew W. Bazemore, MD, MPH

    While policy makers emphasize increased use of preventive care as central to health reform's ability to lengthen lives and save costs, busy clinicians still lack financial incentives to coordinate and effect evidence-based prevention. To realize these ambitions, the Department of Health and Human Services should align payments from the CMS with the preventive evidence base produced by the USPSTF. Simultaneously, Congress should implement innovative payment reforms driving new models of preventive coordination and accountability, revisit previously authorized but unnecessary services, and increase support for research on their effectiveness and cost-effectiveness.

  • Estimated Effects of "America's Affordable Health Choices Act of 2009"10 page PDF

    Monographs & Books | Sep 15, 2009 | Robert Graham Center

    House draft bill H.R. 3200 was introduced in the House on July 13, 2009. Since then it has undergone committee consideration and a mark-up session. Section 1721 of HR 3200 relates to payments to primary care physicians and “requires that State Medicaid programs reimburse for primary care services furnished by physicians and other practitioners at no less than 80% of Medicare rates in 2010, 90% in 2011, and 100% in 2012 and after.” It further “maintains the Medicare payment differentials between physicians and other practitioners. The federal government would pay 100% of the incremental costs attributable to this requirement.” This white paper reports on analyses to assess and estimate the effects of Section 1721 of draft bill HR 3200 on the total gross revenue of the average physician nationally and the total gross revenue of the average family physician in each state. It shows the widely variable but important impact.

  • A Comparison of Chronic Illness Care Quality in US and UK Family Medicine Practices Prior to Pay-for-Performance Initiatives

    Articles | Sep 11, 2009 | Jesse Crosson, PhD ; Pamela Ohman-Strickland, PhD; Stephen Campbell, MD; Robert L Phillips, MD, MSPH; Martin O Roland, PhD; Evangelos Kontopantelis, PhD; Andrew Bazemore, MD, MPH; Bijal Balasubramanian, MBBS, PhD; and Benjamin Crabtree, PhD

    The Quality and Outcomes Framework (QOF) has contributed to modest improvements in chronic illness care in the UK. US policymakers have proposed similar pay-for-performance (P4P) approaches to improve care.

  • How States Will Solve the Healthcare Workforce Crisis: What to Ask For from the Feds50 page PDF

    Presentations | Jun 15, 2009 | Bob Phillips, MD, MSPH

    How states will solve the healthcare workforce crisis: What to ask for from the Feds

  • Health Care Reform Depends on Family Medicine: Walk Softly Keep the Stick Close44 page PDF

    Presentations | Jun 15, 2009 | Bob Phillips, MD, MSPH

    Health care reform depends on family medicine: Walk softly but keep the stick close

  • Effects of proposed primary care incentive payments on average physician Medicare revenue and total Medicare allowed charges14 page PDF

    Monographs & Books | May 15, 2009 | Robert Graham Center

    The US Senate Finance Committee and the Medicare Payment Advisory commission have both proposed incentive payments for primary care physicians who meet certain thresholds of "primary care-ness." With the support of the AAFP Foundation, the Graham Center analyzed how many physicians would meet proposed thresholds, and the potential impact on both physician revenue and Medicare costs. A 60% threshold (60% of claims dollars are for home, nursing home, or office visits) will capture about 60% of family physicians but only 40% of general internists. This suggests that a substantial bonus may influence more primary care physicians to deliver more primary care. But because it excludes more rural physicians than urban, these threshold codes may also be excluding physicians doing a broader scope of appropriate primary care. We do not yet suggest additional codes to be considered but suggest that Congress and the Administration need to re-evaluate their choices to avoid the unintended consequence of overly restricting the range of services needed for the Patient Centered Medical Home.

  • Is Colorado Ready for a Primary Care-based Health Care System?72 page PDF

    Presentations | Apr 15, 2009 | Bob Phillips, MD MSPH and Andrew Bazemore, MD MPH

    Is Colorado ready for a primary care-based health care system?

  • Medical School Expansion, Primary Care, and Policy: Engaging Primary Care Educators in Evidence-Based Advocacy68 page PDF

    Presentations | Apr 15, 2009 | Andrew Bazemore, MD, MPH; Julie Phillips, MD, MPH; Amy McGaha, MD; Hope Wittenberg, MA

    Medical school expansion, primary care, and policy: Engaging primary care educators in evidence-based advocacy

  • Universal Primary Care34 page PDF

    Presentations | Mar 26, 2009 | Michael Fine, MD, and Shannon Brownlee, MS

    Universal Primary Care - Health Care. Reform. Shovel Ready Now

  • How Can Primary Care Cross the Quality Chasm?

    Articles | Mar 15, 2009 | Solberg LI; Elward KS; Phillips WR; Gill JM; Swanson G; Main DS; Yawn BP; Mold JW; and Phillips RL Jr

    The chasm between knowledge and practice decried by the Institute of Medicine (IOM) is the result of other chasms that have not been addressed. They include the chasm between what we know and what we need to know to improve care; the chasm between those who provide primary care and those who do not fund, study, support, or publish practical primary care studies; and the chasm between research and quality improvement (QI). These chasms are a result of problematic concepts, attitudes, traditions, time frames, and financing approaches among the various participants. If we are to facilitate the production and use of the knowledge needed for primary care to cross IOM’s chasm, major changes are needed. These changes include the following: (1) admission by all primary care professions that we have quality problems that require our unified attention and action; (2) conversion of the paradigm from “translate research into practice” to “optimizing health and health care through research and QI”; (3) development and facilitation of more partnerships among clinicians, researchers, and care delivery leaders for engaged scholarship in both research and QI; (4) modification of the agendas and methods of funders and researchers so they emphasize the problems of patients and patient care and support practical time frames and research designs; and (5) facilitation by funders and journals of the dissemination and implementation of lessons from QI and practical research.

  • The Robert Graham Center Update: A Primary Care Perspective on Health Care Workforce and Expenditures50 page PDF

    Presentations | Mar 15, 2009 | Robert Graham Center

    A compendium of slides for public use that includes original and adapted analyses, commentary, and annotation from the staff of the Robert Graham Center.

  • Health Care: The Next Mortgage Crisis32 page PDF

    Presentations | Mar 15, 2009 | ichael Fine, MD, and Shannon Brownlee, MS

    Health Care: The Next Mortgage Crisis

  • What the Federal Government Should Do to Revitalize the Primary Care Practice Infrastructure & Quality in the United States37 page PDF

    Presentations | Jan 15, 2009 | Kevin Grumbach, MD

  • Characterizing Breast Symptoms in Family Practice

    Articles | Nov 15, 2008 | Margaret Eberl, Bob Phillips, Henk Lamberts, Inge Okkes, and Martin Mahoney

    PURPOSE: The frequency and outcome of breast symptoms have not been well characterized in primary care settings. To enhance and inform physician practice, this study aims to establish the proportion of visits and resultant diagnoses by age by examining longitudinal data on breast-related reasons for encounter. METHODS: We used data from a prospective longitudinal sample of patients seeking care in Dutch family physician offices between 1985 and 2003 to provide routine family practice data on breast symptoms as the reason for encounter; all visits were coded using the International Classification of Primary Care. Data on breast symptom prevalence are based upon 84,285 active female patients and 367,834 total encounters. RESULTS: Overall breast symptoms were reported in about 3% of all visits by female patients (29.7 per 1,000 active female patients per year); breast pain and breast mass were the most common breast-related complaints. Breast symptom complaints were highest among women aged 25 to 44 years (48 of 1,000) and among women aged 65 years and older (33 per 1,000). Of the women complaining of breast symptoms, 81 (3.2%) had breast cancer diagnosed. Breast mass had a markedly elevated positive likelihood ratio for breast cancer (15.04; 95% confidence interval, 11.74-19.28). CONCLUSIONS: As expected, of patients with breast symptoms only a small subset was subsequently given a diagnosis of breast cancer (3.2%); however, the presence of a breast mass was associated with an elevated likelihood of breast cancer. These data illustrate the use of systematic data collection and classification from primary care offices to extract information regarding disease symptoms and diagnoses.

  • Primary Care in the ACO: The Role of Primary Care in the Future Healthcare System1 page PDF

    Presentations | Nov 14, 2008 | Erica Brode, MD MPH; Andrew Bazemore, MD, MPH; Kevin Grumbach, MD

  • Common Measures, Better Outcomes: A Field Test of Brief Health Behavior Measures in Primary Care

    Articles | Nov 01, 2008 | Douglas Fernald , MA; Desiree Froshaug, MS; Miriam Dickinson, PhD; Bijal Balasubramanian, MBBS, PhD; Martey Dodoo, PhD; Jodi Summers Holtrop, PhD; CHES, Dorothy Hung, PhD, MA, MPH; Russell Glasgow, PhD; Linda Niebauer; and Larry Green, MD

    Primary care offices have been characterized as underutilized settings for routinely addressing health behaviors that contribute to premature death and unnecessary suffering. Practical tools are needed to routinely assess multiple health risk behaviors among diverse primary care patients. The performance of a brief set of behavioral measures used in primary care practice is reported here.

  • Primary Care's Eroding Earnings: Is Congress Concerned

    Articles | Sep 15, 2008 | Yoshi Laing, Thomas Bodenheimer, Bob Phillips, and Andrew Bazemore

    PURPOSE: Despite increasing data demonstrating the positive impact primary care has on quality of care and costs, our specialty faces uncertainty. Its popularity among medical students is declining, and the income gap is growing between primary care and other specialties. Congress has the power to intervene in this impending crisis. If we want to influence lawmakers' actions, we need to know how they are thinking about these issues. METHODS: Using a set of questions covering several physician payment topics, we interviewed 14 congressional staff aides (5 aides on Medicare-oversight committees, 9 general staff aides) and one representative from each of 3 governmental agencies: the Medicare Payment Advisory Commission, Congressional Budget Office, and Government Accountability Office. RESULTS: Interviewees revealed that issues in primary care are not high on the congressional agenda, and that Medicare's Sustainable Growth Rate (SGR) is the physician-payment issue on the minds of congressional staff members. CONCLUSION: Attempts to solve primary care's reimbursement difficulties should be tied to SGR reform.

  • Access Transformed: Building a Primary Care Workforce in the 21st Century40 page PDF

    Monographs & Books | Aug 15, 2008 | Robert Graham Center

    Access transformed: Building a primary care workforce for the 21st century

  • The Robert Graham Center Update 200847 page PDF

    Presentations | Jul 15, 2008 | Robert Graham Center

    A compendium of slides for public use that includes original and adapted analyses and commentary from the staff of the Robert Graham Center.

  • A Perfect Storm: Changes Impacting Medicare Threaten Primary Care Access in Underserved Areas

    One Pagers | Jun 15, 2008 | Imam Xierali, PhD; Andrew Bazemore, MD MPH; Bob Phillips, MD MSPH; Stephen Petterson, PhD; Martey Dodoo, PhD and Bridget Teevan, MIS

    A convergence of three policies could reduce physician Medicare payments by 14.9 to 22.3 percent in 2008, which could jeopardize access for Medicare beneficiaries in underserved areas. Congress and the Executive Branch should coordinate their roles in setting Medicare payment policy, because their overlapping decisions can have additive impact.

  • Testing Process Errors and Their Harms and Consequences Reported from Family Medicine Practices: A sSudy of the American Academy of Family Physicians National Research Network

    Articles | Jun 15, 2008 | Hickner J, Graham DG, Elder NC, Brandt E, Emsermann CB, Dovey S, Phillips R

    CONTEXT: Little is known about the types and outcomes of testing process errors that occur in primary care. OBJECTIVE: To describe types, predictors and outcomes of testing errors reported by family physicians and office staff. DESIGN: Events were reported anonymously. Each office completed a survey describing their testing processes prior to event reporting. SETTING AND PARTICIPANTS: 243 clinicians and office staff of eight family medicine offices. MAIN OUTCOME MEASURES: Distribution of error types, associations with potential predictors; predictors of harm and consequences of the errors. RESULTS: Participants submitted 590 event reports with 966 testing process errors. Errors occurred in ordering tests (12.9%), implementing tests (17.9%), reporting results to clinicians (24.6%), clinicians responding to results (6.6%), notifying patient of results (6.8%), general administration (17.6%), communication (5.7%) and other categories (7.8%). Charting or filing errors accounted for 14.5% of errors. Significant associations (p<0.05) existed between error types and type of reporter (clinician or staff), number of labs used by the practice, absence of a results follow-up system and patients' race/ethnicity. Adverse consequences included time lost and financial consequences (22%), delays in care (24%), pain/suffering (11%) and adverse clinical consequence (2%). Patients were unharmed in 54% of events; 18% resulted in some harm, and harm status was unknown for 28%. Using multilevel logistic regression analyses, adverse consequences or harm were more common in events that were clinician-reported, involved patients aged 45-64 years and involved test implementation errors. Minority patients were more likely than white, non-Hispanic patients to suffer adverse consequences or harm. CONCLUSIONS: Errors occur throughout the testing process, most commonly involving test implementation and reporting results to clinicians. While significant physical harm was rare, adverse consequences for patients were common. The higher prevalence of harm and adverse consequences for minority patients is a troubling disparity needing further investigation.

  • Brakes for a Runaway Train?48 page PDF

    Presentations | May 23, 2008 | Cathy Schoen, MS

    Brakes for a Runaway Train? The Medical Home's Role in Containing U.S. Health Care Expenditures

  • Physician Distribution and Access: Workforce Priorities

    One Pagers | May 15, 2008 | Xingyou Zhang, PhD; Bob Phillips, MD MSPH; Andrew Bazemore, MD MPH; Martey Dodoo, PhD; Stephen Petterson, PhD; Imam Xierali, PhD, and Larry A. Green, MD

    Most Primary Care Health Professional Shortage Areas (HPSAs) exceed federal population-to-physician designation criteria, yet struggle to maintain access to primary care physicians. Policy options for recruiting and retaining primary care physicians to HPSAs, and new HPSA criteria that support access to primary care practices, should be considered.

  • GIS and General Practice: Where are we going and when will we get there?41 page PDF

    Monographs & Books | Jan 15, 2008 | Dr. Paul Grinzi, Department of General Practice, University of Melbourne, Australia

    GIS and General Practice: Where are we going and when will we get there? A REPORT FROM THE 2007 APHCRI / ROBERT GRAHAM CENTER VISITING FELLOWSHIP

  • Genomics and Healthcare: Will Primary Care Lead or Follow?37 page PDF

    Presentations | Dec 15, 2007 | Greg Feero, MD, PhD

    Genomics and health care: Will primary care lead or follow?

  • The Patient Centered Medical Home: History, seven core features, evidence and transformational change32 page PDF

    Monographs & Books | Nov 15, 2007 | Robert Graham Center

    The Patient Centered Medical Home: History, seven core features, evidence and transformational change

  • Data Standards Paths4 page PDF

    Presentations | Oct 15, 2007 | David Kibbe, MD, MBA, and Steven Waldren, MD, MS

    Harmonizing primary care clinical classification and data standards: Expert panel presentaions - Data Standards Paths

  • Coding Medical Constructs: Creating Chaos out of Order11 page PDF

    Presentations | Oct 15, 2007 | Wilson Pace, MD

    Harmonizing primary care clinical classification and data standards: Expert panel presentations - Coding medical constructs: Creating chaos out of order

  • Primary Care Data Standards: What Do We Have now? What Do We Still Need?16 page PDF

    Presentations | Oct 15, 2007 | Michael Klinkman, MD, MS

    Harmonizing primary care clinical classification and data standards: Expert panel presentaions - Primary care data standards: What do we have now? What do we still need?

  • Harmonizing Primary Care: Clinical Classification and Data Standards132 page PDF

    Monographs & Books | Oct 15, 2007 | Robert L. Phillips, Jr., MD, MSPH; Michael Klinkman, MD, MS; and Larry A. Green, MD

    Harmonizing primary care clinical classification and data standards

  • Why Is It So Important to Have Organizing Principles and Data Standards for Primary Care?12 page PDF

    Presentations | Oct 10, 2007 | Larry Green, MD

    Harmonizing primary care clinical classification and data standards: Expert panel presentions - Why is it so important to have organizing principles and data standards for primary care?

  • Some History of this Ground11 page PDF

    Content Type, Presentations | Oct 10, 2007 | Maurice Woods, MD

    Harmonizing primary care clinical classification and data standards: Expert panel presentations: Some History of this Ground

  • Access Granted: The Primary Care Payoff24 page PDF

    Monographs & Books | Aug 15, 2007 | Robert Graham Center

    Access granted: The primary care payoff

  • Access Denied: A Look at America's Medically Disenfranchised42 page PDF

    Monographs & Books | Aug 01, 2007 | The Robert Graham Center, National Association of Community Health Centers

  • Seeking a Replacement for the Medicare Physician Services Payment Method: A New Approach Improves Health Outcomes and Achieves Budgetary Savings

    Articles | Jul 15, 2007 | Martey Dodoo, Bob Phillips, Larry Green

    Business and government spending on physician services have soared over the last few decades. Most payers for services traditionally peg their payment rates to Medicare. However, most consider the current Medicare single payment rate flawed because it fails to improve health outcomes or control spending. Everyone wants to replace it, but good replacements have not been identified. We estimated elasticities of the single-payment rate with respect to several of its determinants, proposed a replacement--a service-specific payment rate--for the single-payment rate, and estimated the budget implications of this replacement. Key findings are that the single-payment rate is relatively inelastic to the Sustained Growth Rate (SGR) and expenditure levels and that the proposed service-specific payment rate promotes primary care, controls spending, and saves money.

  • Primary Care Value Propositions31 page PDF

    Presentations | Jun 15, 2007 | Robert Phillips, MD, MSPH

    Primary care value proposition

  • Use of Patient Registries in U.S. Primary Care Practices

    One Pagers | Jun 01, 2007 | Larry Green, MD et. al.

    Patient registries are necessary for high-quality health care, but even in innovative practices, their presence and utilization is inadequate. Registry uptake in primary care may be enhanced by improving the functionality of electronic health records (EHRs) and implementing payment models that reward registry use.

  • Rural Origins and Choosing Family Medicine Predict Future Rural Practice

    One Pagers | Jun 01, 2007 | JL Hyer, MB; Andrew Bazemore, MD, MPH; RC Bowman; Xingyou Zhang, PhD; Stephen Petterson, PhD; Robert Phillips, MD, MSPH

    The shortage of physicians in U.S. rural practice may impact access to health care for one in five citizens. Two medical student characteristics that predict eventual practice in rural settings are clear: being born in a rural county and choosing a residency in family medicine.

  • Imperative Integration: Medical Care for Older Patients

    One Pagers | Oct 01, 2006 | Larry Green, MD, et. al.

    The ecology of medical care changes for older people, with increases in usage of residential and institutional care, emergency departments, and home care. Care integrated across multiple settings, as is proposed for new models of primary care, is essential for the care of older patients.

  • Learning from Different Lenses: Reports of Medical Errors in Primary Care by Clinicians, Staff, and Patients

    Articles | Sep 15, 2006 | Robert L. Phillips, Susan M. Dovey, Deborah Graham, Nancy C. Elder and John M. Hickner

    OBJECTIVES: To test whether family doctors, office staff, and patients will report medical errors and to investigate differences in how and what they report. METHODS: Clinicians, staff, and patients in 10 family medicine clinics of the American Academy of Family Physicians National Research Network representing a diversity of clinical and community settings were invited to report errors they observed. They were asked to report routinely during 10 weeks and to report every error on 5 specific days. They submitted anonymous reports via a Web site, paper forms, and a voice-activated phone system. RESULTS: Four hundred one clinicians and staff reported 935 errors within 717 events, 37% (265) of which came from the 5 intensive reporting days and 61% (440) from routine reports. Staff made 384 (53%) reports, and clinicians, 342 (47%) reports. Most (96%) errors reported were process errors, not related to knowledge or skill. Staff reported more errors in patient flow and communication; clinicians reported more medication and laboratory errors. Reports suggest that patients with complex health issues (31% versus 20%, P = 0.013) are vulnerable to more severe outcomes. Patients submitted 126 reports, 18 of which included errors. CONCLUSIONS: Clinicians and staff offer different and independently valuable lenses for understanding errors and their outcomes in primary care, but both predominantly reported process- or system-related errors. There is a clear need to find more effective ways to invite patients to report on errors or adverse events. These findings suggest that patient safety organizations authorized by recent legislation should invite reports from a variety of health care workers and staff.

  • Prometheus: Igniting Payment Reform2 page PDF

    Presentations | Jun 15, 2006 | Francois DeBrantes National Coordinator Bridges to Excellence

    Prometheus: Igniting payment reform

  • Healthstat: Making America's Health Care More Affordable43 page PDF

    Presentations | Feb 15, 2006 | R. Eric Hart, MD

    HealthSTAT: Making America's health care more affordable

  • Excess, Shortage, or Sufficient Physician Workforce: How Could We Know?

    One Pagers | Nov 01, 2005 | Martey Dodoo, PhD; Robert Phillips, MD, MSPH; Larry Green, MD; Ginger Ruddy, MD; Jessica McCann, MD; Lawrence Klein, PhD

    At least three models have been used to project the future physician workforce, and each produces different results. No physician workforce predictions can be relied on until there is more consideration of and agreement on desired health outcomes and what physicians must do to achieve them.

  • Physician Workforce: Legal Immigrants will Extend Baby Boom Demands

    One Pagers | Oct 15, 2005 | Martey Dodoo, PhD; Robert Phillips, MD, MSPH; Larry Green, MD; Ginger Ruddy, MD; Jessica McCann, MD; Lawrence Klein, PhD

    The baby boom generation will place large demands on the Medicare program and the U.S. health care system. These demands may be extended by a large legal immigrant population that will become Medicare-eligible soon after the baby boom generation does. The U.S. health care system should be prepared for sustained stress from this aging population.

  • Physician Assistant and Nurse Practitioner Workforce Trends

    One Pagers | Oct 01, 2005 | Jessica McCann, MD; Robert Phillips, MD, MSPH; Edward O'Neil, MD; Ginger Ruddy, MD; Martey Dodoo, PhD' Lawrence Klein, PhD

    The physician assistant (PA) and nurse practitioner (NP) workforces have realized explosive growth, but this rate of growth may be declining. Most PAs work outside primary care; however, the contributions of PAs and NPs to primary care and interdisciplinary teams should not be neglected.

  • COGME's 16th Report to Congress: Too Many Physicians Could be Worse than Wasted

    Commentaries & Editorials | May 15, 2005 | Robert L. Phillips, Jr., MD, MSPH; Martey Dodoo, PhD; Carlos R. Jaen, MD, PhD; and Larry A. Green, MD

    Departing from past reports, the latest Council on Graduate Medical Education (COGME) report warns of a physician deficit of 85,000 by 2020 and recommends increases in medical school and residency output. COGME notes that contributions of other clinicians and changes in how medical care is delivered in the future would likely offset physician deficits but chose not to modify their recommendations. COGME offers a relatively minor workforce correction in an otherwise flawed system of health care; however, the nation awaits a reassessment of its physician workforce based on what the nation wants and needs from physicians working in modern systems of care. Great caution should be exercised in expanding the physician workforce. Producing a physician surplus could be far worse than wasted, because the investment required and resulting rise in health care cost may harm, not help, the health of people in the United States. Instead, these resources could be applied in ways that improve health.

  • Adding More Specialists is Not Likely to Improve Population Health: Is Anybody Listening?

    Commentaries & Editorials | Mar 24, 2005 | Robert L. Phillips Jr., MD, MSPH; Martey S. Dodoo, and Larry A. Green, MD

    Before a shortage of physicians, and particularly subspecialists, in the United States is declared, it is worth reviewing the considerable evidence that calls into question whether further specialization automatically improves health. should lead to purposeful choices about what we want them to do and the outcomes we expect.

  • What if We Were Equal? A Comparison of the Black-White Mortality Gap in 1960 and 2000

    Articles | Mar 15, 2005 | David Satcher, George E. Fryer, Jr., Jessica McCann, Adewale Troutman, Steven H. Woolf, George Rust

    The United States has made progress in decreasing the black-white gap in civil rights, housing, education, and income since 1960, but health inequalities persist. We examined trends in black-white standardized mortality ratios (SMRs) for each age-sex group from 1960 to 2000. The black-white gap measured by SMR changed very little between 1960 and 2000 and actually worsened for infants and for African American men age thirty-five and older. In contrast, SMR improved in African American women. Using 2002 data, an estimated 83,570 excess deaths each year could be prevented in the United States if this black-white mortality gap could be eliminated.

  • Avoiding and Fixing Medical Errors in General Practice: Prevention Strategies Reported in the Linnaeus Collaboration's Primary Care International Study of Medical Errors

    Articles | Jan 15, 2005 | Murray Tilyard, Susan Dovey and Katherine Hall

    OBJECTIVE: To report tactics for avoiding and remedying medical errors observed by general practitioners in New Zealand and five other countries. METHODS: The Primary Care International Study of Medical Errors collected 66 reports of medical errors in New Zealand and 363 reports from general practitioners in Australia, Canada, England, the Netherlands, and the United States. Strategies for avoiding and overcoming errors were grouped by themes, for New Zealand and the five other countries combined. RESULTS: In all New Zealand reports and 336 (92.6%) reports from other countries, doctors offered at least one error prevention idea. The largest category of suggestions was ‘more diligence’ (New Zealand: 69.7% of reports, other countries: 55.3%). Other strategies were: ‘provide care differently’ (New Zealand 22.7%, other countries 36.4%); ‘improve communication’ (19.7% and 17.8% of reports); ‘education’ (7.8% and 11.0% of reports); and ‘more resources’ (12.1% and 14.0% of reports). CONCLUSIONS: In general practitioners’ medical errors reports, a culture of individual blame is more evident than recognized need for systems design. A minority of reports contained specific, pragmatic suggestions for changing health care systems to protect patients’ safety. Error reporting systems may be a practical way to generate innovative solutions to potentially harmful problems facing general practice patients.

  • Report to the Task Force on the Care of Children by Family Physicians79 page PDF

    Monographs & Books | Jan 15, 2005 | Robert L. Phillips, Jr., MD, MSPH; Martey S. Dodoo, PhD; Jessica L. McCann, MA; Andrew Bazemore, MD; George E. Fryer, PhD; Lisa S. Klein; Michael Weitzman, MD; Larry A. Green, MD

    Report to the Task Force on the care of children by family physicians

  • The Health Impact of Resolving Racial Disparities: An Analysis of U.S. Mortality Data

    Articles | Dec 15, 2004 | Steven H. Woolf, MD, MPH; Robert E. Johnson, PhD; George E. Fryer, Jr, PhD, MSW; George Rust MD, MPH; and David Satcher, MD, PhD

    The U.S. health system spends far more on the "technology" of care (e.g., drugs, devices) than on achieving equity in its delivery. For 1991 to 2000, we contrasted the number of lives saved by medical advances with the number of deaths attributable to excess mortality among African Americans. Medical advances averted 176 633 deaths, but equalizing the mortality rates of Whites and African Americans would have averted 886202 deaths. Achieving equity may do more for health than perfecting the technology of care.

  • The Physician Workforce of the United States: A Family Medicine Perspective,The Physician Workforce of the United States: A Family Medicine Perspective197 page PDF

    Monographs & Books | Oct 15, 2004 | Larry A. Green, MD; Martey S. Dodoo, PhD; Ginger Ruddy, MD; George E. Fryer, PhD; Robert L. Phillips, MD, MSPH; Jessica L. McCann, MA; Edward H. O’Neil, MPA, PhD, FAAN; Lisa S. Klein

    The physician workforce of the United States: A family medicine perspective

  • The Importance of Having Health Insurance and a Usual Source of Care

    One Pagers | Sep 15, 2004 | Robert Phillips, MD, MSPH; M Proser; Larry Green, MD; Ed Fryer, PhD; Jessica McCann, MD; Martey Dodoo, PhD

    The effects of insurance and having a usual source of care are additive. Efforts to improve health care access for all should provide a medical home and health insurance.

  • A String of Mistakes: The Importance of Cascade Analysis in Describing, Counting, and Preventing Medical Errors

    Articles | Aug 15, 2004 | Steven H. Woolf, MD, MPH; Anton J. Kuzel, MD, MHPE; Susan M. Dovey, MPH, PhD; and Robert L. Phillips, Jr., MD, MSPH

    BACKGROUND: Notions about the most common errors in medicine currently rest on conjecture and weak epidemiologic evidence. We sought to determine whether cascade analysis is of value in clarifying the epidemiology and causes of errors and whether physician reports are sensitive to the impact of errors on patients. METHODS: Eighteen US family physicians participating in a 6-country international study filed 75 anonymous error reports. The narratives were examined to identify the chain of events and the predominant proximal errors. We tabulated the consequences to patients, both reported by physicians and inferred by investigators. RESULTS: A chain of errors was documented in 77% of incidents. Although 83% of the errors that ultimately occurred were mistakes in treatment or diagnosis, 2 of 3 were set in motion by errors in communication. Fully 80% of the errors that initiated cascades involved informational or personal miscommunication. Examples of informational miscommunication included communication breakdowns among colleagues and with patients (44%), misinformation in the medical record (21%), mishandling of patients’ requests and messages (18%), inaccessible medical records (12%), and inadequate reminder systems (5%). When asked whether the patient was harmed, physicians answered affirmatively in 43% of cases in which their narratives described harms. Psychological and emotional effects accounted for 17% of physician-reported consequences but 69% of investigator-inferred consequences. CONCLUSIONS: Cascade analysis of physicians’ error reports is helpful in understanding the precipitant chain of events, but physicians provide incomplete information about how patients are affected. Miscommunication appears to play an important role in propagating diagnostic and treatment mistakes.

  • How Family Physicians are Funded in the United States

    Commentaries & Editorials | Jul 15, 2004 | Larry A. Green

    How family physicians are funded in the United States

  • Future of Family Medicine Recommendations Confirm Need for Increased Research From Family Physicians

    Articles | Jun 15, 2004 | Larry A. Green

    Future of family medicine recommendations confirm need for increased research from family physicians

  • Few People in the United States can Identify Primary Care Physicians

    One Pagers | May 15, 2004 | Mary Stock Keister, MD; Larry Green, MD; Norman Kahn, MD; Robert Phillips, MD, MSPH; Jessica McCann. MD; Ed Fryer, PhD

    Almost one decade after the Institute of Medicine defined primary care, only one-third of the American public is able to identify any of the medical specialties that provide it, and only 17% were able to accurately distinguish primary care physicians from medical or surgical specialists and non-physicians. This lack of discrimination compromises the goal of achieving primary care for all and merits immediate attention.

  • What People Want from Their Family Physician

    One Pagers | May 15, 2004 | Mary Stock Keister, MD; Larry Green, MD; Norman Kahn, MD; Robert Phillips, MD, MSPH; Jessica McCann, MD; Ed Fryer, PhD

    The public wants and is satisfied by care provided within a patient-physician relationship based on understanding, honesty and trust. If the U.S. healthcare system is ever to become patient-centered, it must be designed to support these values and sustain, rather than fracture, relationships people have with their primary physician.

  • The Research Domain of Family Medicine

    Articles | May 15, 2004 | Larry A. Green, MD

    This article characterizes the large research domain of family medicine. It is a domain that can be productively explored from different perspectives, including: (1) the ecology of medical care and its focus on the environments of health care and interactions among them (2) the realm of causation and important opportunities to discover how people lose and regain their health (3) knowing medicine in different ways, focusing on what things mean in the inner and outer realities of individuals and groups of individuals (4) the nature of the work of family physicians, such as first-contact care for any type of problem, sticking with patients regardless of their diagnoses, incorporating context into decision making, development of relevant technologies, articulating useful theory, and measuring what happens in family medicine (5) the standard research categories of basic, clinical, health services, health policy, and educational research, and (6) thinking of family medicine research as both a linear process of translation and a wheel of knowledge with iterative loops of discovery that come from within family medicine. The domain of family medicine research is important and ripe for fuller discovery, and it invites the thinking and imagination of the best investigators. It seems unlikely that medical research can ever be complete without a robust family medicine research enterprise. As the domain of family medicine research is explored, not a few, but billions of people will benefit.

  • Learning from Malpractice Claims about Negligent, Adverse Events in Primary Care in the United States

    Articles | Apr 15, 2004 | RL Phillips Jr, LA Bartholomew, SM Dovey, GE Fryer JR, TJ Miyoshi and LA Green

    BACKGROUND: The epidemiology, risks, and outcomes of errors in primary care are poorly understood. Malpractice claims brought for negligent adverse events offer a useful insight into errors in primary care. METHODS: Physician Insurers Association of America malpractice claims data (1985–2000) were analyzed for proportions of negligent claims by primary care specialty, setting, severity, health condition, and attributed cause. We also calculated risks of a claim for condition-specific negligent events relative to the prevalence of those conditions in primary care. RESULTS: Of 49 345 primary care claims, 26 126 (53%) were peer reviewed and 5921 (23%) were assessed as negligent; 68% of claims were for negligent events in outpatient settings. No single condition accounted for more than 5% of all negligent claims, but the underlying causes were more clustered with "diagnosis error" making up one third of claims. The ratios of condition-specific negligent event claims relative to the frequency of those conditions in primary care revealed a significantly disproportionate risk for a number of conditions (for example, appendicitis was 25 times more likely to generate a claim for negligence than breast cancer). CONCLUSIONS: Claims data identify conditions and processes where primary health care in the United States is prone to go awry. The burden of severe outcomes and death from malpractice claims made against primary care physicians was greater in primary care outpatient settings than in hospitals. Although these data enhance information about error related negligent events in primary care, particularly when combined with other primary care data, there are many operating limitations.

  • The New Model of Primary Care: Knowledge Brought Dearly24 page PDF

    Monographs & Books | Mar 15, 2004 | Robert L. Phillips, Jr., MD, MSPH; Larry A. Green, MD; George E. Fryer, Jr., PhD; Jessica McCann, MA

    The new model of primary care: Knowledge bought dearly

  • The Ecology of Medical Care for Children in the United States: A New Application of an Old Model Reveals Inequities That Can be Corrected

    One Pagers | Dec 15, 2003 | Susan Dovey, MD, MPH; Larry Green, MD; Ed Fryer, PhD; Robert Phillips, MD, MSPH

    If equal and adequate access to health care for children in the United States is a goal, we are failing. That failing is most prominent in the setting where most children receive care and preventive services—the doctor’s office.

  • Using Geographic Information Systems to Understand Health Care Access

    Articles | Nov 10, 2003 | Robert L. Phillips, Jr., MD MSPH, Michael L. Parchman, MD, Thomas J. Miyoshi, MSW

    Determining a community's health care access needs and testing interventions to improve access are difficult. This challenge is compounded by the task of translating the relevant data into a format that is clear and persuasive to policymakers and funding agencies. Geographic information systems can analyze and transform complex data from various sources into maps that illustrate problems effortlessly for experts and nonexperts.

  • The U.S. Primary Care Physician Workforce: Undervalued Service

    One Pagers | Oct 15, 2003 | Holly Biola, MD; Larry Green, MD; Robert Phillips, MD MSPH; Janelle Guirguis-Blake, MD; Ed Fryer, PhD

    Primary care physicians work hard, but their compensation is not correlated to their work effort when compared with physicians in other specialties. This disparity contributes to student disinterest in primary care specialties.

  • The U.S. Primary Care Physician Workforce: Minimal Growth 1980-1999

    One Pagers | Oct 15, 2003 | Holly Biola, MD; Larry Green, PhD; Robert Phillips, MD, MSPH; Janelle Guirguis-Blake, MD; ED Fryer, PhD

    Growth in the primary care physician workforce (physicians per capita) in the United States has trailed the growth of the specialist physician population in recent years. This has occurred despite calls during the same period for increased production of primary care physicians and educational reforms focusing on primary care.

  • The Need for Research in Primary Care

    Articles | Oct 15, 2003 | Jan M De Maeseneer, Mieke L van Driel, Larry A Green and Chris van Weel

    Making evidence from scientific studies available to clinical practice has been expected to directly improve quality of care, but this expectation has not been realised. The notion of quality of care is complex, and quality improvement needs medical, contextual, and policy evidence. In primary care, research is needed that takes into account the specific characteristics of its population and the presentation and prevalence of illness and disease. The context of the doctor-patient encounter plays a major part, and needs better understanding. At the policy level, issues of equity must be addressed. The knowledge base for family practice must be expanded by integration of multiple methods of comprehension, so we can bridge the gap between evidence and practice.

  • Why Does a U.S. Primary Care Physician Workforce Crisis Matter?

    Commentaries & Editorials | Oct 15, 2003 | Robert L. Phillips, Jr. MD, MSPH, and Barbara Starfield, MD, MPH

    Offers evidence that a primary care workforce crisis may once again be taking shape. The 1990s saw alignment of public policy and funding efforts to increase the primary care workforce, and indeed family medicine training capacity grew by 34 percent.

  • Family Physicians Are an Important Source of Newborn Care: The Case of the State of Maine

    One Pagers | Aug 15, 2003 | Donna Cohen, PhD; Janelle Guirguis-Blake, MD; David Jack, MD; V.K. Chetty, PhD; Larry Green, MD; Ed Fryer, PhD; Robert Phillips, MD, MSPH

    Family physicians (FPs) provided 30 percent of inpatient newborn care in Maine in the year 2000. FPs cared for a large proportion of newborns, especially those insured by Medicaid and in smaller, rural hospitals where FPs also delivered babies. Family medicine’s commitment to serve vulnerable populations of newborns requires continued federal, state, and institutional support for training and development of future FPs.

  • Family Physicians Make a Substantial Contribution to Maternity Care: The Case of the State of Maine

    One Pagers | Aug 01, 2003 | Donna Cohen, PhD; Janelle Guirguis-Blake, MD; David Jack, MD; V.K. Chetty, PhD; Larry Green, MD; Ed Fryer, PhD; Robert Phillips, MD, MSPH

    Family physicians provided nearly 20 percent of labor and delivery care in Maine in the year 2000. A substantial proportion of this care was provided to women insured by Medicaid and those delivering in smaller, rural hospitals and residency-affiliated hospitals. As family medicine explores its future scope, research identifying regional variations in the maternity care workforce may clarify the need for maternity care training in residency and labor and delivery services in practice.

  • Family Physicians' Solutions to Common Medical Errors

    One Pagers | Mar 15, 2003 | Susan Dovey, MD, MPH; Larry Green, MD; Ed Fryer, PhD; Robert Phillips, MD, MSPH

    In two U.S. studies about medical errors in 2000 and 2001, family physicians offered their ideas on how to prevent, avoid, or remedy the five most often reported medical errors. Almost all reports (94 percent) included at least one idea on how to overcome the reported error. These ideas ranged from “do not make errors” (34 percent of all solutions offered to these five error types) to more thoughtfully proposed solutions relating to improved communication mechanisms (30 percent) and ways to provide care differently (26 percent). More education (7 percent) and more resources such as time (2 percent) were other prevention ideas.

  • Consequences of Medical Errors Observed by Family Physicians

    One Pagers | Mar 01, 2003 | Susan Dovey, MD, MPH; Larry Green, MD; Ed Fryer, PhD; Robert Phillips, MD, MSPH

    In two studies about medical errors, family physicians reported health, time, and financial consequences in nearly 85 percent of their error reports. Health consequences occurred when the error caused pain, extended or created illness, or placed patients, their families, and others at greater risk of harm. Care consequences included delayed diagnosis and treatment (sometimes of serious health conditions such as cancer), and disruptions to care that sometimes even resulted in patients needing care in a hospital. Other important consequences were financial and time costs to patients, health care providers, and the health system generally. However, sometimes no consequence was apparent.

  • Types of Medical Errors Commonly Reported by Family Physicians

    One Pagers | Feb 15, 2003 | Susan Dovey, MD, MPH; Larry Green, MD; Ed Fryer, PhD; Robert Phillips, MD, MSPH

    In a group of studies about medical errors in family medicine, the five error types most often observed and reported by U.S. family physicians were: (1) errors in prescribing medications; (2) errors in getting the right laboratory test done for the right patient at the right time; (3) filing system errors; (4) errors in dispensing medications; and (5) errors in responding to abnormal laboratory test results. “Errors in prescribing medications” was the only one of these five error types that was also commonly reported by family physicians in other countries.

  • Family Physicians Increase Provision of Well-Infant Care Despite Decline in Prenatal Services

    One Pagers | Jan 01, 2003 | Janelle Guirguis-Blake, MD; Ed Fryer, PhD; Mark Deutchman, MD, MPH; Larry Green, PhD; Susan Dovey, MD, MPH; and Robert Phillips, MD, MSPH

    Over the past 20 years, both FP/GPs and pediatricians have upheld their commitment to preventive care for infants. Non-Metropolitan Statistical Areas (non-MSAs) depend on family physicians for almost half of their well-infant care. In fact, FP/GPs have increased their overall provision of well-infant care despite a decline in delivery of prenatal services. This commitment to child health care demands continued excellence of FP training in pediatric medicine, preventive care, and child advocacy.

  • Family Physicians' Declining Contribution to Prenatal Care in the United States

    One Pagers | Dec 15, 2002 | Janelle Guirguis-Blake, MD; Ed Fryer, PhD; Mark Deutchman, MD; Larry Green, MD; Susan Dovey, MD, MPH; Robert Phillips, MD, MSPH

    There has been a substantial decline in prenatal care by family physicians over the past 20 years in all geographic regions of the country. Even so, during the past two decades, FP/GPs have provided over two million prenatal visits per year. As the field re-explores future scope, it should consider the erosion of the provision of prenatal care, its effect on the U.S. population and the specialty, and possibilities for revitalization of prenatal care in residency curricula and practice.

  • Family Physicians Are the Main Source of Primary Health Care for the Medicare Population

    One Pagers | Dec 01, 2002 | James Mold, MD, MPH; Ed Fryer, PhD; Robert Phillips, MD, MSPH; Susan Dovey, MD, MPH; Larry Green, MD

    Of people 65 years and older who reported an individual provider as their usual source of health care, 60 percent identified a family physician or general practitioner. The Medicare population relies heavily on family physicians.

  • Classification of Medical Errors and Preventable Adverse Events in Primary Care: A Synthesis of the Literature

    Articles | Nov 15, 2002 | Elder NC, Dovey SM

    OBJECTIVE: To describe and classify process errors and preventable adverse events that occur from medical care in outpatient primary care settings. STUDY DESIGN: Systematic review and synthesis of the medical literature. DATA SOURCES: We searched MEDLINE and the Cochrane Library from 1965 through March 2001 with MESH term medical errors, modified by adding family practice, primary health care, physicians/family, or ambulatory care and limited the search to English-language publications. Published biblographies and web sites from patient safety and primary care organizations were also reviewed for unpublished reports, presentations, and leads to other sites, journals, or investigators with relevant work. Additional papers were identified from the references of the papers reviewed and from seminal papers in the field. OUTCOMES MEASURED: Process errors and preventable adverse events. RESULTS: Four original research studies directly studied and described medical errors and adverse events in primary care, and 3 other studies peripherally addressed primary care medical errors. A variety of quantitative and qualitative methods were used in the studies. Extraction of results from the studies led to a classification of 3 main categories of preventable adverse events: diagnosis, treatment, and preventive services. Process errors were classified into 4 categories: clinician, communication, administration, and blunt end. CONCLUSIONS: Original research on medical errors in the primary care setting consists of a limited number of small studies that offer a rich description of medical errors and preventable adverse events primarily from the physician's viewpoint. We describe a classification derived from these studies that is based on the actual practice of primary care and provides a starting point for future epidemiologic and interventional research. Missing are studies that have a patient, consumer, or other health care provider input.

  • A Preliminary Taxonomy of Medical Errors in Family Practice

    Articles | Sep 15, 2002 | Dovey SM, Meyers DS, Phillips RL, Green LA, Fryer GE, Galliher JM, Kappus J, Grob P

    OBJECTIVE: To develop a preliminary taxonomy of primary care medical errors. DESIGN: Qualitative analysis to identify categories of error reported during a randomized controlled trial of computer and paper reporting methods. SETTING: The National Network for Family Practice and Primary Care Research. PARTICIPANTS: Family physicians. MAIN OUTCOME MEASURES: Medical error category, context, and consequence. RESULTS: Forty-two physicians made 344 reports: 284 (82.6%) arose from healthcare systems dysfunction; 46 (13.4%) were errors due to gaps in knowledge or skills; and 14 (4.1%) were reports of adverse events, not errors. The main subcategories were: administrative failures (102; 30.9% of errors), investigation failures (82; 24.8%), treatment delivery lapses (76; 23.0%), miscommunication (19; 5.8%), payment systems problems (4; 1.2%), error in the execution of a clinical task (19; 5.8%), wrong treatment decision (14; 4.2%), and wrong diagnosis (13; 3.9%). Most reports were of errors that were recognized and occurred in reporters' practices. Affected patients ranged in age from 8 months to 100 years, were of both sexes, and represented all major US ethnic groups. Almost half the reports were of events which had adverse consequences. Ten errors resulted in patients being admitted to hospital and one patient died. CONCLUSIONS: This medical error taxonomy, developed from self-reports of errors observed by family physicians during their routine clinical practice, emphasizes problems in healthcare processes and acknowledges medical errors arising from shortfalls in clinical knowledge and skills. Patient safety strategies with most effect in primary care settings need to be broader than the current focus on medication errors.

  • Family Practice in the United States: Position and Prospects

    Articles | Aug 15, 2002 | Green LA, Fryer GE

    Family practice became the 20th U.S. medical specialty in 1969. It has delivered on its promise to reverse the decline of general practice and care for people with diverse problems in all areas of the country. But many important health care problems remain unsolved, in part because of poor role delineation for family physicians, poor differentiation of family practice from other fields, and insufficient changes in the cultural and political environment. Family practice's problems include confusion about whether it is a reform movement or an incumbent specialty; disagreement about its role in controlling and assuring care; confusion about whether family physicians are generalists or specialists; lack of clarity about family practice as vital for all versus a possible option for some; misunderstanding about the knowledge requirements for family practice; and inadequate business models. Family practice's mistakes include expending much effort on justification and less on assuring practical means to accomplish its work; permitting an erosion of public trust; failing to strengthen relationships with interfacing specialties and organizations; and neglecting research. Nonetheless, there are promising opportunities to improve health and health care through strengthening family practice that depend in part on redesigning the family practice setting, defining carefully critical interactions with other elements of the health care system, fostering discovery of family practice, and further differentiating family practice as a scientific and caring field. Another period of adaptation by family practice is already under way; this may be the first time in history that its ambitious aspirations are actually achievable.

  • What Physicians Need to Know About Seniors and Limited Prescription Benefits and Why

    One Pagers | Jul 15, 2002 | Chien-Wen T, Susan Dovey, MD, MPH; Larry Green, MD; Ed Fryer, PhD; Robert Phillips, MD, MSPH

    More and more often, seniors are faced with outpatient prescription benefits that have annual spending limits and may be forced to cut back on use of medications when they run out of benefits before the end of the year. Family physicians can play a valuable role by helping seniors choose the best value medications for their budgets and by checking whether or not seniors can afford their prescriptions.

  • First Morning Back

    Articles | Jun 15, 2002 | Larry A. Green, MD

    This diary-based report documented the increasing difficulty of practicing in primary care settings. Medical knowledge and skills are, in general, the easy part; getting into a position to apply them is the challenge.

  • The Delicate Task of Workforce Determination

    Commentaries & Editorials | Mar 15, 2002 | Dovey SM, Green LA, Phillips RL, Fryer GE

    The delicate task of workforce determination

  • Patients' Rights in the United States: From 'Down-Under' the Situation Seems Upside-Down

    Articles | Feb 15, 2002 | Gauld R

    Patients' rights in the United States: From 'down-under' the situation seems upside-down

  • It Takes a Balanced Health Care System to Get it Right

    Commentaries & Editorials | Dec 15, 2001 | Green LA, Dovey SM, and Fryer GE

    It takes a balanced health care system to get it right

  • Taking Necessary Steps to Position U.S. Health Care to be the Best

    Articles | Nov 15, 2001 | Larry A Green

    Taking necessary steps to position U.S. health care to be the best

  • Trumping Professional Roles: Collaboration of Nurse Practitioners and Physicians for a Better U.S. Health Care System

    One Pagers | Oct 15, 2001 | Susan Dovey, MD, MPH; Larry Green, MD; Ed Fryer, PhD

    Professional turf battles have yielded variations in the scope of practice for nurse practitioners (NPs) obstructing collaboration with physicians that would enhance patient care. Patients would be better served if NPs and physicians worked together to develop better combined models of education and service that take advantage of the benefits of both professions' contributions to care.

  • The Ecology of Medical Care Revisited

    Articles | Oct 15, 2001 | Green LA, Fryer GE, Yawn BP, Lanier D, Dovey SM

    The ecology of medical care revisited

  • The Contemporary Ecology of U.S. Medical Care Confirms the Importance of Primary Care

    One Pagers | Sep 15, 2001 | Susan Dovey, MD, MPH; Larry Green, MD; Ed Fryer, PhD; Robert Phillips, MD, MSPH

    More women, men, and children receive medical care each month in the offices of primary care physicians than any other professional setting. There is an urgent need for health policies that encourage further innovation and implementation of first-rate primary care for everyone.

  • The Patient Safety Grid: Toxic Cascades in Health Care Settings

    One Pagers | Mar 15, 2001 | Susan Dovey, MD, MPH; Larry Green, MD; Ed Fryer, PhD; Robert Phillips, MD, MSPH

    The Patient Safety Grid shows the fields where action is necessary in a comprehensive national effort to reduce harm from medical errors. Each segment of the grid is important and connected to others, sometimes forming a toxic cascade.

  • Toxic Cascades: A Comprehensive Way to Think About Medical Errors

    One Pagers | Mar 01, 2001 | Susan Dovey, MD, MPH; Larry Green, MD; Ed Fryer, PhD; Robert Phillips, MD, MSPH

    Current thinking about threats to patient safety caused by medical errors is often focused in hospital on the immediate consequences of mistakes that affect specific aspects of care, such as testing procedures or medications. Some mistakes, however, become apparent distant from where they were committed and only after a lapse in time. The model of a toxic cascade organizes an approach to making U.S. health care safer for patients by locating upstream sources and downstream consequences of errors within a comprehensive, multilevel scheme.

  • The Importance of Primary Care Physicians as the Usual source of Health Care in the Achievement of Prevention Goals

    One Pagers | Nov 01, 2000 | Susan Dovey, MD, MPH; Larry Green, MD; Ed Fryer, PhD

    Having a usual source of care enhances achieving clinical prevention goals for both children and adults. There is room for improvement, and differences between the practices of internists and family physicians suggest that slightly longer visits and having health insurance might contribute to achieving proven prevention strategies.

  • The Importance of Having a Usual Source of Health Care

    One Pagers | Aug 01, 2000 | Susan Dovey, MD, MPH; Larry Green, MD; Ed Fryer, PhD

    Most people (82%) in the United States have and use for much of their health care a usual source of care, and a majority of them name a particular primary care physician as that source. Regardless of self-reported health status, people benefit from having a usual source of health care even if they are uninsured.

  • Putting Practice into Research: A 20-Year Perspective

    Articles | Jun 01, 2000 | Larry Green, MD

    Since the 1982 article in Family Medicine focused on sentinel practices as an aspiration, practice based research networks (PBRNs) have become a fixture in the world of primary care. This perspectives piece reviews the origins and development of practice based research networks, their contribution to healthcare advancement, and their evolving role into the future.

  • Rhetoric, Reality and Revolution in Family Practice and Primary Care

    Articles | Dec 01, 1999 | Larry Green, MD

    It is distressing to an observer from south of Canada to read the paper from the Ontario College of Family Physicians (Rosser and Kasperski). It indicates disruption and confusion within an admirable healthcare system - a system with a reputation of getting things right when it comes to family practice and primary care. Apparently, all is not well.