Does de-implementation of low-value care impact the patient-clinician relationship? A mixed methods study

Background The importance of reducing low-value care (LVC) is increasingly recognized, but the impact of de-implementation on the patient-clinician relationship is not well understood. This mixed-methods study explored the impact of LVC de-implementation on the patient-clinician relationship. Methods Adult primary care patients from a large Virginia health system volunteered to participate in a survey (n = 232) or interview (n = 24). Participants completed the Patient-Doctor Relationship Questionnaire (PDRQ-9) after reading a vignette about a clinician declining to provide a low-value service: antibiotics for acute sinusitis (LVC-antibiotics); screening EKG (LVC-EKG); screening vitamin D test (LVC-vitamin D); or an alternate vignette about a high-value service, and imagining that their own primary care clinician had acted in the same manner. A different sample of participants was asked to imagine that their own primary care clinician did not order LVC-antibiotics or LVC-EKG and then respond to semi-structured interview questions. Outcomes data included participant demographics, PDRQ-9 scores (higher score = greater relationship integrity), and content analysis of transcribed interviews. Differences in PDRQ-9 scores were analyzed using one-way ANOVA. Data were integrated for analysis and interpretation. Results Although participants generally agreed with the vignette narrative (not providing LVC), many demonstrated difficulty comprehending the broad concept of LVC and potential harms. The topic triggered memories of negative experiences with healthcare (typically poor-quality care, not necessarily LVC). The most common recommendation for reducing LVC was for patients to take greater responsibility for their own health. Most participants believed that their relationship with their clinician would not be negatively impacted by denial of LVC because they trusted their clinician’s guidance. Participants emphasized that trusted clinicians are those who listen to them, spend time with them, and offer understandable advice. Some felt that not providing LVC would actually increase their trust in their clinician. Similar PDRQ-9 scores were observed for LVC-antibiotics (38.9), LVC-EKG (37.5), and the alternate vignette (36.4), but LVC-vitamin D was associated with a significantly lower score (31.2) (p < 0.05). Conclusions In this vignette-based study, we observed minimal impact of LVC de-implementation on the patient-clinician relationship, although service-specific differences surfaced. Further situation-based research is needed to confirm study findings.

Pre-eclampsia and hypertensive disorders of pregnancy

Hypertensive disorders of pregnancy, including pre-eclampsia, are a significant and commonly encountered group of medical disorders of pregnancy. A primary care clinician is ideally placed to screen for, diagnose and, if confident, initiate management in antenatal and postnatal women. Early involvement of maternity services is advised if a hypertensive disorder in pregnancy is suspected or diagnosed. Checking of maternal blood pressure and urinalysis should be encouraged during all routine appointments with pregnant women. The aim of this article is to provide an overview of the hypertensive disorders of pregnancy, their diagnosis and management in primary care, with a review of commonly used antihypertensive agents in current UK clinical practice.

Does De-Implementation of Low Value Care Impact the Patient-Clinician Relationship? A Mixed Methods Study

Background: The importance of reducing low-value care (LVC) is increasingly recognized, but the impact of de-implementation on the patient-clinician relationship is not well understood. This mixed-methods study explored the impact of LVC de-implementation on the patient-clinician relationship. Methods: Adult primary care patients from a large Virginia health system volunteered to participate in a survey (n=232) or interview (n=24). Participants completed the Patient-Doctor Relationship Questionnaire (PDRQ-9) after reading a vignette about a clinician declining to provide a low-value service: antibiotics for acute sinusitis (LVC-antibiotics); screening EKG (LVC-EKG); screening vitamin D test (LVC-vitamin D); or a comparison vignette about a high-value service, and imagining that their own primary care clinician had acted in the same manner. A different sample of participants was asked to imagine that their own primary care clinician did not order LVC-antibiotics or LVC-EKG and then respond to semi-structured interview questions. Outcomes data included participant demographics, PDRQ-9 scores (higher score = greater relationship integrity), and content analysis of transcribed interviews. Differences in PDRQ-9 scores were analyzed using one-way ANOVA. Data were integrated for analysis and interpretation. Results: Although participants generally agreed with the vignette narrative (not providing LVC), many demonstrated difficulty comprehending the broad concept of LVC and potential harms. The topic triggered memories of negative experiences with healthcare (typically poor-quality care, not necessarily LVC). The most common recommendation for reducing LVC was for patients to take greater responsibility for their own health. Most participants believed that their relationship with their clinician would not be negatively impacted by not receiving the described service because they trusted their clinician’s guidance. Participants emphasized that trusted clinicians are those who listen to them, spend time with them, and offer understandable advice. Some felt that not providing LVC would actually increase their trust in their clinician. Similar PDRQ-9 scores were observed for LVC-antibiotics (38.9), LVC-EKG (37.5), and the comparison vignette (36.4), but LVC-vitamin D was associated with a significantly lower score (31.2) (p<0.05). Conclusions: Findings suggest minimal impact of LVC de-implementation on the patient-clinician relationship, although service-specific differences may exist. Further research on enhancing patient trust through LVC de-implementation is needed.

Focal Periphyseal Oedema: A Physiologic Finding in Paediatric Knee Pain

Knee pain is a common reason for adolescent calls or visits to a primary care clinician. The authors present a case of an 14-year-old male adolescent with progressive bilateral nociceptive somatic knee pain. The pain was worse with weight bearing, and relieved at rest. It was located over the medial joint line. The patient was treated conservatively with nonsteroidal anti-inflammatory drugs and a rehabilitation program. Magnetic Resonance Imaging (MRI) showed bone marrow oedema, and Focal Periphyseal Oedema (FOPE) diagnosis was made. After a total of 6 months of treatment, the patient was asymptomatic. The literature is limited to a few case reports and radiologic studies describing this symptomatic physeal pathology, not reporting physical examination or treatment. The goals of this case report were to elucidate physicians of this condition, a newly reported cause of knee pain in adolescent, and to elicit the importance of a patient-tailored rehabilitation program in the treatment of this finding. FOPE is a clinical entity that should not be ignored and must be treated for the patient’s comfort. It is a self-limited condition and has an excellent prognosis.

207 Patients’motivations and expectations when seeking urgent care at emergency departments and acceptability of primary care streaming: a realist study

Aims/Objectives/BackgroundWe aim to explain the contexts and mechanisms that influence patients’ motivations and expectations when accessing urgent care at an ED and their acceptability of being streamed to a primary care clinician working in or alongside the ED. Recent healthcare policy has encouraged the implementation of primary care services in or alongside emergency departments whereby patients with low acuity illness are streamed to a primary care clinician after a brief initial assessment. Our findings describe patients’ motivations, expectations, and acceptability of primary care streaming and their level of satisfaction.Methods/DesignWe recruited 24 patients to be interviewed after visiting an emergency department for one of five low acuity complaints. 12 patients were streamed to ED clinicians and 11 were streamed to primary care clinicians. We carried out semi-structured realist style interviews by telephone and carried out a realist analysis to create theories to explain motivations to attend, acceptability of streaming and satisfaction with care.Results/ConclusionsMotivations for attending the ED included patients’ perception of their complaint as an emergency which needed immediate treatment, and previous experience of receiving care at the ED. Acceptability of primary care streaming was related to patients’ past experiences accessing primary care services, their trust in initial assessment processes and their expectation to be seen by ‘expert clinicians’ on the ‘same day’. When patients’ expectations of waiting times, level of investigations and general quality of care were met or exceeded, they reported acceptability to being streamed to a primary care clinician and were satisfied with their care. Understanding why patients attend the ED for urgent care needs and their experience of primary care streaming is essential to addressing increasing ED demand and improving efficiency.

Characterization and Comparison of Primary Care Appointment Utilization Patterns Among Military Health System Beneficiaries

Introduction The role of primary care in the United States is vitally important to improving health outcomes, minimizing waste, and controlling cost. The Military Health System is tasked with both caring for its beneficiaries and ensuring the medical readiness of active duty service members, who often have needs unique to those in the civilian population. Balancing the number of individuals assigned to a primary care clinician with the clinician’s capacity to meet their medical needs and anticipated appointment demand is a fundamental cornerstone of effective primary care clinic management in any setting. Materials and methods Using the Military Health System Data Repository, this cross-sectional study utilized descriptive statistics and Poisson regression to describe crude and adjusted primary care appointment utilization trends among Military Health System beneficiaries during fiscal year 2016. Results The primary care appointment utilization rate of the study population was 3.3 visits per person-year. The youngest and oldest age groups, women, active duty, and those enrolled to Army clinics had the highest utilization rates within each of the respective covariates. Active duty women had the highest utilization of any group in the data set, with a crude rate of 4.7 visits per person-year. Conclusions Primary care utilization trends are different among different demographic subgroups within the Military Health System (MHS). Unmet demand, patient acuity, clinician continuity, robustness of team support, and other important factors that influence appointment utilization were not incorporated in this study. Superficially, these data suggest that the MHS enrollment target of 1,100–1,300 patients per full-time primary care clinician is roughly appropriate, though this should be interpreted with caution given the limitations.