Family Practice rediscovered

A new trend in American health care is the patient-centered medical home. The approach revolves around a team of medical and health professionals who, working together, treat an individual, led by a primary-care physician who orchestrates the whole effort. The goal is the team knows everything about the patient, no matter how disparate the symptoms—from the earache last night to the long history of high cholesterol—and works together to treat the individual in a holistic way.

 

Patient-centered medical homes (PCMH) have gained popularity since the National Committee on Quality Assurance recognized them five years ago. There are more than 1,500 such practices recognized by the nonprofit health quality association.

Yet despite their growing popularity, questions remain about their effectiveness. In a new study, researchers at the University of Iowa evaluated a similar model being tested with military veterans, and conclude that maintaining a direct, regular channel of communication between the patient and the primary doctor is critical to success.

“This is a time of intense change in health care, and all of these aspects (with PCMHs) potentially contribute to more fragmentation,” says David Katz, associate professor in internal medicine at the UI and the corresponding author on the study, published in the Journal of General Internal Medicine. “That’s why we can’t lose sight of the doctor-patient relationship, and how we’re communicating with our physicians.”

Katz and his colleagues surveyed 4,393 veterans receiving care in medical facilities in the upper Midwest run by the U.S. Department of Veterans Affairs (VA) to evaluate their thoughts on the VA’s Patient Aligned Care Team initiative, an approach to care much like the PCMH. The veterans needed to have at least three primary-care visits during the survey period, which lasted from 2009 to 2010.

In particular, the researchers sought to better understand whether continuity of care—measured by the concentration of visits with a primary-care physician and the duration of care with that physician—led to a patient feeling more satisfied with his or her relationship with the primary doctor.

The research team found that it did, mainly because continuity of care seems to yield better communication between the individual and the primary-care doctor and thus a happier patient overall.

“I think that’s a very simple implication of this study,” Katz says, “in the sense that it can improve the connectedness of the patient and improve the quality of the doctor-patient communication and the patient’s satisfaction with their care.”

The researchers found that the surveyed VA patients reported seeing their assigned care provider 80 percent of the time, higher than anticipated and comparable with rates in the private sector. Yet only half rated as “excellent” their involvement with a primary physician in making a treatment decision in the past year.

Katz noted that several factors could influence the rating, such as if a patient had an acute problem that needed immediate treatment, reducing the time available for an involved discussion. Nevertheless, “part of it could improve with better training of physicians how to engage patients in shared decision making and giving patients more instruction on how to approach a primary-care visit,” says Katz, also an associate professor in the College of Public Health.

The study looked at the patient-doctor relationship with treatment decisions. Katz noted further studies should examine screening and diagnostic visits.

“What it all boils down to,” Katz says, “is we have to make sure that during this time of primary-care redesign, that we pay attention to what is happening to the doctor-patient relationship and communication in particular.”