New Research Shows Complexity of Primary Care

January 26, 2016 11:31 am Michael Laff

A recently published study involving individuals with diabetes offers insight into the complex health problems that family physicians and other primary care physicians help their patients manage.

[Female physician checking the blood-sugar level of diabetic female patient]

Researchers at the Robert Graham Center for Policy Studies in Family Medicine and Primary Care tackled the question of how the complexity of primary care visits compares with that of subspecialist visits in a study report titled "Complexity of Ambulatory Care Visits of Patients With Diabetes as Reflected by Diagnoses per Visit"(www.primary-care-diabetes.com) that was published online this month in Primary Care Diabetes. The study measured the complexity of patient visits based on the number of chronic conditions each patient with diabetes reported and the number of reasons for each office visit.

The study showed that a total of 48 percent of all visits made by patients with diabetes and no other chronic conditions were to primary care physicians, defined in the study as family physicians/general practitioners, internists and geriatricians. This dropped to 45 percent for those with one other chronic condition, 44 percent for those with two to four other chronic conditions and 39 percent for those with five or more other chronic conditions.

Story Highlights
  • Researchers from the Robert Graham Center for Policy Studies in Family Medicine and Primary Care sought to measure the complexity of primary care visits using data from patients with diabetes.
  • Patients with diabetes made more visits to subspecialists, but those visits were more likely to involve only a single diagnosis.
  • One author said the study could offer insight into the need to adjust payment based on the complexity of a patient visit.

In general, patients with diabetes made more visits to subspecialists than to primary care physicians, but those subspecialist visits were more likely to involve only a single diagnosis. Specifically, about 70 percent of visits by adults with diabetes in which only one diagnosis was reported were to subspecialist physicians; the remaining 30 percent were to primary care physicians.

"In contrast, multiple diagnoses were more common in visits to primary care physicians," the authors wrote, referring to the fact that almost 90 percent of visits for which four diagnoses were reported were to a primary care physician. "Overall, complexity of the office visit, as reflected by the number of visit diagnoses reported, is found to be higher for primary care physicians than for subspecialist physicians."

The study was based on survey responses from 4,500 patients with diabetes who were, on average, age 61. Patients were asked how many times they visited a physician, what types of specialists they met with and the medical reasons for their visits, among other questions.

"This research suggests that patients will continue to rely on primary care physicians to care for their chronic conditions," the authors wrote.

Researchers chose to study visit complexity by examining data from patients with diabetes because 29 million individuals were diagnosed with the disease in 2012 and they often struggle with additional chronic conditions. As a result, such patients frequently visit a primary care physician as well as one or more subspecialists.

"A family physician needs a broad level of training to address all conditions, and they are not focused on a single condition," said Miranda Moore, Ph.D., a health services researcher at the Graham Center and the lead author of the study.

The survey did not include patients who received treatment in hospitals or the ER, and researchers could not identify precisely how many conditions a physician considered during each visit. Patients of subspecialists, in particular, might not mention additional conditions as reasons for a visit because they think the other conditions are outside the physician's area of expertise.

"When patients are thinking about their own individual health conditions, they think of the specialist as the provider, but for their overall health the perception is that the primary care physician is treating all of their conditions," Moore said.

The study may provide greater understanding of the need to adjust payment based on the complexity of a patient visit.

"The current fee-for-service reimbursement model is based on volume of care, not necessarily on multiple dimensions of complexity related to the cognitive ability needed to provide whole-person care," Moore said. "This research demonstrates that there are avenues for measuring complexity that need to be explored when crafting new payment policy."

Related AAFP News Coverage
How Would You Describe a 'Complex' Patient?
Researchers Seek to Update Existing Complexity Models

(9/18/2015)

More From AAFP
American Family Physician: Graham Center Policy One-Pager: Accounting for Complexity: Aligning Current Payment Models with the Breadth of Care by Different Specialties


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