International Journal for Quality in Health Care 15:371-373 (2003)
© 2003 International Society for Quality in Health Care
Editorial |
Challenges and opportunities for primary care evaluation
Approximately 60% of the 823 million outpatient visits in the United States during the year 2000 were to primary care physicians [1], and this proportion is higher in most other countries. A large body of literature supports the value of primary care; however, surprisingly little is known about the optimal timing, content, and quality of visits in the primary care setting. Moreover, tools to compare primary care providers at the level of the organization, health plan, medical group, or individual provider are limited. Yet, such data could help employers and patients choose providers of primary care, and could also be used for quality improvement, physician education and training, or to reward providers of high quality care.This issue of the International Journal for Quality in Health Care includes two articles evaluating practice in the primary care setting. In the first, DeSalvo et al. examined the revisit interval assigned by resident physicians in an academic primary care clinic [2], building on a handful of previous studies on this topic [3–7]. The authors demonstrate substantial variability in revisit intervals that is most strongly related to the practice styles of individual physicians. This finding underscores the scarcity of evidence about the optimal timing of return visits and the large variations in practice that result. With little guidance from the literature and no widely accepted standards of practice, physicians devise their own practice styles or emulate those of other physicians.
As the authors note, the study’s focus on physicians in training at one institution limits its generalizibility. Moreover, other unmeasured factors may be important contributors to decisions about the revisit interval. Nevertheless, the large variations in revisit intervals reveal opportunities for additional work in this area. For example, physician focus groups may identify beliefs and attitudes about appropriate revisit intervals, and larger observational studies could assess the average duration between visits for patients with certain conditions. With such additional data, expert panels of physicians might offer recommendations about revisit intervals. Studies assessing the impact of recommended revisit intervals on outcomes could then be performed. Developing evidence-based standards for revisit intervals could promote more efficient and effective use of health care resources.
In a second article evaluating primary care practice in this issue, Enzer et al. present preliminary findings about a new instrument designed to measure competence of general practitioners in office-based visits [8]. The authors demonstrate that the instrument can be administered by trained medical or lay raters, and can provide reliable data about important elements of the physician–patient interaction. The study is limited by the small sample size and questions about the generalizability of the instrument outside Great Britain. Nevertheless, this tool could increase knowledge about the content of primary care visits and the interpersonal relationships between patients and their physicians. Important future work includes using the instrument to identify the elements of patient–provider interactions that are most strongly associated with outcomes, such as patient satisfaction, adherence, and trust. A related challenge includes learning how to implement such tools not only for research purposes, but also for evaluating and training physicians, and improving the quality of care being delivered to patients.
With improvements in the science of quality measurement over the last decade, quality indicators are now available that can provide information about the provision of preventive services, some chronic disease care, and hospital care [9–11]. In addition, tools now exist to assess patients’ experiences with hospital care or health plans [12,13]. Yet, as the field of quality measurement continues to develop, certain challenges and opportunities for quality measurement in the primary care setting should be recognized. These issues arise from the first contact, longitudinal, and comprehensive nature of primary care [14,15].
Firstly, the assessment of interpersonal aspects of care is not yet part of routine quality measurement. However, the long-term nature of primary care relationships and the impact of psychosocial factors on patients’ overall health underscore the importance of evaluating and improving the quality of patient–physician interactions. Patients value information and generally want to be involved in decisions about their care [16]. Better patient–physician interactions are associated with more trusting and longer-term relationships [17], and patients with greater trust in their physicians are more satisfied with their care, more likely to adhere to their physicians’ recommendations, and less likely to change physician [18,19]. Evaluating and improving patient–physician interactions may have a large impact on the quality of information exchanged between patients and their providers, and on subsequent care. Unfortunately, such data can be difficult to collect, often requiring video or audio tapes or detailed questioning of patients. Instruments such as the one evaluated by Enzer et al. in this issue [8] may advance this component of quality measurement.
A second challenge for quality measurement in primary care is the insufficient evidence base for much of the care delivered. For example, physicians recommended hormone replacement therapy for the prevention of heart disease for years before a randomized trial was conducted [20]. In addition, many clinical trials recruit patients with a single disease, rather than combinations of diseases or non-specific symptoms, common among patients presenting to primary care providers. As evident in the article by DeSalvo et al. [2], even straightforward questions such as appropriate timing of return visits lack data to guide clinical decisions. Such uncertainty about best practice is associated with large variations in care [21]. Understanding these variations and improving the evidence base regarding problems frequently encountered in the primary care setting is crucial to increase the consistency and quality of care delivered. From an increased evidence base will follow improvements in primary care practice evaluation.
Thirdly, most available quality indicators, such as ß-blocker use after myocardial infarction and hemoglobin A1c measurement in diabetes, are disease-based. Although this approach allows comparisons of patients with similar conditions, the comprehensive and first-contact nature of primary care means that most providers encounter a broad range of presenting problems and often address multiple problems at once. Moreover, each provider may care for only a small number of eligible patients for any given indicator. Furthermore, evidence-based guidelines and appropriateness criteria, such as those available for acute myocardial infarction and pneumonia, are often not available for symptom-oriented problems commonly encountered in the primary care setting, such as fatigue or headaches.
Finally, as providers of first contact and comprehensive care, primary care providers have a special role in determining the need for referrals and coordinating care from multiple providers. Yet, tools to measure the appropriateness of referral decisions, communication between providers, and the coordination of care remain limited. Such measurement will be increasingly important as patients grow older and survive longer with multiple complex medical problems. Moreover, new strategies are needed to manage the vast amount of information that is relevant to primary care, and for coordinating care and communicating with other providers. As such strategies and tools are developed, they will require careful evaluation.
Many questions remain about how to improve health care delivery in the primary care setting. For example, how should primary care practices be organized? To what extent should telephone contacts, e-mail, web-based tools, group visits, and physician extenders be used to decrease the frequency of patient visits with their physicians, particularly for managing chronic disease? How should information technology be applied to the practice of primary care? How should incentives be structured to improve care? How can access to primary care be expanded? How can the rising costs of care be controlled? And ultimately, how can we assure that patients receive high-quality, multi-dimensional care that respects their preferences and involves their families appropriately?
Evaluation of primary care is important to answering these questions. Such evaluation must reflect the various roles of primary care providers, including first-contact care of substantial breadth to care for patients with straightforward and complex health problems, health promotion and preventive care, referral decisions, and coordination of care. It must also incorporate evaluation of interpersonal interactions between patients and their physicians. Expanding the evidence base for primary care and evaluating the quality of that care with rigorous new methods will be essential to improving the health and experiences of patients in the years ahead.
Department of Medicine, Brigham and Women’s Hospital and Department of Health Care Policy, Harvard Medical School Boston, MA, USA
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