Survey Yields New Insights Into Primary Care

What really happens during a clinical primary care encounter? A survey to tackle that question has unearthed some surprises, according to an article in the January/February issue of Annals of Family Medicine. The survey data on primary care clinicians, patients and services in some cases differ dramatically from results of a survey in wide use, say the article's authors.

"Describing Primary Care Encounters: The Primary Care Network Survey and the National Ambulatory Medical Care Survey" (PDF file: 9 pages / 249 KB. More about PDFs.) introduces a new survey called the Primary Care Network Survey, or PRINS. That survey was taken by about 900 primary care clinicians, including pediatricians, family physicians, internists, residents, advanced practice nurses or nurse practitioners, and physician's assistants, in 20 primary care practice-based research networks, or PBRNs, including AAFP's National Research Network.

The authors compare results from the PRINS with results from the National Ambulatory Medical Care Survey, or NAMCS, which is a leading tool used to describe primary health care services. The authors of the Annals article, led by Helen Binns, M.D., M.P.H., director of the Pediatric Practice Research Group at Northwestern University, Chicago, note some of the limitations of the NAMCS. For example, the NAMCS is restricted to visits to physicians, and its options for diagnostic/assessment and counseling/education services include those pertinent to surgical and medical subspecialties. In addition, very little of the NAMCS information on physicians and their practices is available to the public.

"There is a need to obtain more comprehensive information about primary care clinicians, their patients and services they provide that can be used by researchers, policy-makers and the public," say the authors.

To begin to address that need, in 2001, the Agency for Healthcare Research and Quality, or AHRQ, awarded agreements to 20 primary care PBRNs that worked with AHRQ to develop the PRINS and then conducted the survey. The PRINS is based on recent NAMCS data instruments, but it includes more items to describe assessments and services. Clinicians in the 20 PBRNs completed the PRINS in 2002, with each clinician giving information on approximately 30 patient visits.

The authors studied characteristics of about 600,000 weighted encounters with PRINS clinicians and compared them with characteristics of about 2.1 billion weighted encounters with physicians as reported in five annual cycles of the NAMCS. Larger proportions of PRINS visits involved preventive care and were made by children, members of racial minority groups and individuals without private insurance, say the authors. They add, "These patient groups have health concerns that make them key groups to target when addressing national health priorities."

In examples of the varying data from the two surveys, a diagnostic or other assessment service was performed for 99 percent of PRINS visits versus 76 percent of NAMCS visits. In addition, a preventive or counseling/education service was provided at 64 percent of PRINS visits versus 37 percent of NAMCS visits. Suggesting a need for further improvements in survey tools, the authors caution, "Both PRINS and NAMCS survey methods likely result in an under-reporting of health behavior counseling compared with direct observation."

Noting some similarities in PRINS and NAMCS data, the authors report that an acute problem was the major reason for 49 percent of PRINS visits and 46 percent of NAMCS visits. In addition, blood pressure readings were taken in 59 percent of PRINS visits and 58 percent of NAMCS visits. Also, the top five diagnostic clusters for PRINS and NAMCS visits were the same and included routine health maintenance, upper respiratory infection, hypertension, otitis media and diabetes mellitus.

The authors credit the NAMCS multistage sampling procedure with producing "essentially unbiased national estimates" and suggest, "Viewed in combination, the two data sets (PRINS and NAMCS) may provide an improved understanding of activities undertaken within primary care."

In their discussion of the study, the authors say, "The PRINS data represent the first systematic cataloging of care delivery in primary care offices by a large, diverse group of PBRN members. This national effort presents a new data set that can be used to examine primary care delivery." The authors conclude, "The PRINS data describing primary care delivery among PBRNs are unparalleled in scope."