The patient-centered medical home: will it stand the test of health reform? Initial lessons from the first national demonstration project on practice transformation to a patient-centered medical home.
Ann Fam Med. American Academy of Family Physicians. Joint principles of the patient-centered medical home. Del Med J. Fisher ES. Building a medical neighborhood for the medical home. N Engl J Med. Kirschner N, Greenlee MC. American College of Physicians website. Published Accessed December 4, Yee HF Jr. Ann Intern Med. Referral and consultation communication between primary care and specialist physicians: finding common ground.
Arch Intern Med. Coordinating care in the medical neighborhood: critical components and available mechanisms. Agency for Healthcare Research and Quality website. Published June Association of American Medical Colleges. Innovations at the Interface of Primary and Specialty Care. Evaluating electronic referrals for specialty care at a public hospital. J Gen Intern Med. Impact of a national specialty e-consultation implementation project on access. Am J Manag Care.
Utilization, benefits, and impact of an e-consultation service across diverse specialties and primary care providers. Telemed J E Health. Los Angeles safety-net program eConsult system was rapidly adopted and decreased wait times to see specialists. Health Aff Millwood. Transforming the endocrine consult: asynchronous provider consultations. Endocr Pract. A cost-effectiveness analysis of cardiology eConsults for Medicaid patients. What are the costs of improving access to specialists through eConsultation?
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Milbank Q. Access to specialty care and medical services in community health centers. Differences in specialist consultations for cardiovascular disease by race, ethnicity, gender, insurance status, and site of primary care. Specialists, due to their advanced education and training, possess in-depth, expert understanding of a limited number of diseases within their respective domains and are qualified to perform many diagnostic and therapeutic procedures not in the repertoire of generalists.
Evidence for superior knowledge and practices of specialists in selective diseases is strongest for the care of myocardial infarction and congestive heart failure by cardiologists, depression by psychiatrists, acquired immunodeficiency syndrome AIDS and its complications by infectious disease experts, and some rheumatic and musculoskeletal conditions by rheumatologists.
Interestingly, myocardial infarction and depression are the diseases for which patients express the least confidence in their primary care providers. In other areas, however, generalists outperform specialists. For instance, under open-access esophagogastroduodenoscopy, general internists and family physicians did a better job of scheduling patients for appropriate indications than did internal medicine subspecialists. Furthermore, specialty care may lead to increased costs of care due to overuse of expensive diagnostic and therapeutic interventions in the absence of any additional health benefits.
The cardiologists were less likely to use prophylactic lidocaine, which has been shown to offer no therapeutic benefit, 20 and less likely to use calcium channel blockers, which are potentially harmful. In a national sample of physicians, Chin et al 23 found that cardiologists were more likely than generalists to appropriately use an angiotensin-converting enzyme inhibitor for a hypothetical patient with congestive heart failure. Of patients with positive or very positive exercise stress test results who met additional clinical criteria for necessary coronary angiography, Borowsky et al 26 discovered that after adjustment for sociodemographics and clinical presentation, patients with a cardiologist as a regular source of care were more likely than all other patients to have undergone the procedure within 3 and 6 months.
On the other hand, Stein et al 27 found that, according to published reports and established practice guidelines, noncardiologists ordered more radionuclide stress tests that were not indicated than did cardiologists. Both groups of physicians, however, overused this test. Internists used exercise tests more often for risk stratification and diagnosis; cardiologists performed coronary revascularization procedures 2 to 4 times as often.
While patients of cardiologists had a substantially higher prevalence of established coronary artery disease, patients of internists presented more often with atypical chest pain. Even so, there were no significant differences in the incidence of myocardial infarction or in mortality between the 2 groups.
It is hard to determine whether cardiologists were overly aggressive in their use of procedures or internists not aggressive enough, although the data on underuse of medications, particularly aspirin, shed a negative light on internists and cardiologists alike. The more favorable selection of interventions by cardiologists compared with generalists in treating acute myocardial infarction and congestive heart failure may be secondary to differences in frequency of treating myocardial infarctions; inadequate dissemination of guidelines; differences in continuing medical education programs and recertification procedures; generalists' confusion regarding relative vs absolute contraindications; inadequate feedback to generalists regarding clinical practices; and lack of generalists' participation in clinical trials, dissociating them from involvement in the generation of new therapies.
Support for this idea comes from an analysis of prescribing patterns, which showed that specialists give greater weighting to the beneficial aspects of antihypertensives, while generalists show greater concern over adverse effects. Still, generalists may be slower to adopt new therapies or discard outdated ones secondary to excessive or, at times, appropriate caution. Despite these differences in myocardial infarction and postmyocardial infarction care, McCrory et al 38 found no significant differences in the knowledge and attitudes of generalists and cardiologists regarding anticoagulation for nonvalvular atrial fibrillation in the elderly.
In response to vignettes, however, both groups of physicians underused anticoagulation in this group at high risk of thromboembolic stroke. In the Medical Outcomes Study, 39 no specialty differences in 2- and 4-year outcomes of patients with hypertension were discernible.
Smaller studies 39 , 40 have shown that cardiologists and generalists provided similar quality of care for patients with transient ischemic attacks and stroke. Generalists are not as skillful as psychiatrists at recognizing and treating depression, and they frequently miss clues to suicidal intent. Callahan et al 46 found that even when primary care providers were given diagnostic scales and treatment algorithms, fewer than half of the patients they identified with depression actually received treatment.
The authors attribute this to patient reluctance to take medicines and to physicians' pessimism regarding the effectiveness of treatments. Compared with psychiatrists, however, generalists see a higher percentage of mildly depressed and less-motivated patients in whom the use of antidepressants may not be as effective. In 2 studies, human immunodeficiency virus HIV —infected individuals cared for by generalists had higher odds of hospitalization after diagnosis of their seropositivity 47 and significantly shorter survival 48 than those cared for by an AIDS specialist.
This may have been due to generalists inappropriately delaying initiation of anti-infective therapy, or to specialists' expertise in detecting AIDS-related complications at an earlier stage or in managing complications on an outpatient basis.
In a recent review, Solomon et al 54 concluded that rheumatologists performed arthrocentesis more appropriately than nonrheumatologists for acute monoarthritis and oligoarthritis and produced shorter durations of hospitalization, and that rheumatologists used colchicine during the introduction of urate-lowering therapy for patients with gout more appropriately than generalists.
In a retrospective investigation 55 relying on patient recall, the average rate of progression of functional disability secondary to rheumatoid arthritis was substantially lower in those patients followed up regularly by rheumatologists, likely due to the specialists' more intensive use of second-line antirheumatic medications and more frequent joint surgeries.
Other aspects of rheumatoid arthritis, such as pain control and psychosocial adjustment, were not evaluated. No consistent differences in outcomes between generalists and rheumatologists for patients with lower back pain have been found. The strongest data demonstrating the equivalence of quality of care provided by generalists and specialists comes from the Medical Outcomes Study.
Smaller and less well-designed studies have also shown no differences between generalists and specialists in the management of chronic obstructive lung disease 56 and perinatal outcomes. However, many studies have found superior specialty care in other areas, which may result from greater knowledge and experience. For instance, Fendrick et al 58 surveyed practicing physicians 2 months after a National Institutes of Health Consensus Conference advocated antibiotic therapy for eradication of Helicobacter pylori in patients with peptic ulcer disease.
Despite a low response rate, more gastroenterologists than generalists were aware of, and had adopted, this practice. In 1 small retrospective analysis at 2 community hospitals, 59 pulmonologists disagreed with one third of general internists' spirometry interpretations. Much larger investigations have shown that, when compared with accepted management guidelines, pulmonologists and allergists use more appropriate pharmacotherapy for individuals with asthma than do generalists; generalists tended to underuse inhaled corticosteroids and overuse long-term oral corticosteroids, despite the many adverse effects associated with the prolonged use of these drugs, while underusing high-dose corticosteroids for acute exacerbations.
In 1 study 63 using a convenience sample of physicians to evaluate patient photographs, dermatologists diagnosed the 10 most common skin conditions more accurately, ordered fewer laboratory tests, and prescribed more appropriate treatment than did family practitioners. In a similar investigation, Dolan et al 64 demonstrated differences in university-based primary care physicians' attitudes toward, behaviors in, and knowledge of skin cancer control, compared with dermatologists.
White 65 observed that primary care physicians at 1 clinic underdiagnosed actinic keratoses, using 1 dermatologist's evaluation as a criterion standard. Clement and Christenson 66 found that surveyed internists and family practitioners used the cytobrush less frequently than gynecologists in the collection of Papanicolaou smears.
The authors express concern that this might result in the collection of more false-negative Papanicolaou smears by generalists. Similarly, Starpoli et al 67 found that primary care internal medicine residents at 1 institution often failed to master routine gynecologic skills.
In 2 survey studies, general internal medicine residents displayed knowledge 68 and practice 69 deficits surrounding the care of both pregnant and nonpregnant women with diabetes.
In other areas, findings of more appropriate specialty care may have resulted from patient selection. For instance, most generalists and specialists surveyed by Grisso et al 70 advocated exercise and calcium supplementation for postmenopausal women.
Those patients cared for by endocrinologists and gynecologists were 2 to 4 times as likely as those of general internists to receive estrogen. Alternatively, patient selection of provider may have affected estrogen prescription rates. Both those patients self-referred to endocrinologists and gynecologists and those patients referred by their primary care physicians for, say, a low bone density or severe osteoporosis may have been more likely to choose estrogen replacement therapy for its benefits.
The more typical postmenopausal woman seeing a generalist, on the other hand, may have been less willing to assume the possibly slightly increased risk of breast cancer or the inconvenience of vaginal bleeding that can result from taking estrogen. For instance, intensive, multidisciplinary specialty interventions in individuals with severe asthma have been shown to lead to improved pharmacotherapy, fewer emergency department visits, and reduced admission rates, lengths of hospital stay, and overall costs.
Similar reasoning may also apply to the improved blood glucose control seen in children attending one diabetes specialty clinic. However, a claims-based profile of care provided to Medicare patients with diabetes elucidated that while large proportions of individuals with diabetes received few recommended services eg, hemoglobin A 1C measurements, ophthalmologic evaluation, and cholesterol screening , differences between generalists and specialists were not uniformly large.
In a year statistical overview of 10 randomized controlled trials, most of which were conducted outside the United States, Langhorne et al 79 found a trend toward decreased mortality in patients with stroke cared for in a stroke unit, compared with those hospitalized in a general medical ward.
Horner et al 80 found a similar difference when comparing the outcomes of patients with stroke treated by neurologists and nonneurologists. These results may reflect neurologists' more appropriate management of cerebrovascular accidents and their complications, more intensive care and rehabilitation provided by nurses and physical and occupational therapists, and better education of patients and their families, but appear to be explained best by neurologists' selection of patients with better initial prognoses.
Finally, decreases in mortality in intensive care units with dedicated intensivists 82 - 84 may result from the specialist's superior knowledge and skills. Alternatively, the constant presence or at least immediate availability of a faculty physician to provide bedside care, the institution of patient care protocols and guidelines, increased teaching of house staff and nurses, the establishment of formal daily work rounds, and increased involvement of allied health workers eg, physical therapists may be responsible.
In other instances, within a given organization, superior management of patients by specialists may reflect in part the failure of those specialists to teach their generalist colleagues about properly managing common illnesses or alternatively, the failure of the generalists to learn from specialists' feedback and education regarding management and consultation. Specialized clinics, such as anticoagulation clinics, can help both generalists and specialists better monitor certain aspects of patients' care.
Only some of the studies discussed were prospective, randomized comparisons, 39 , 52 , 72 - 74 and most did not use adequate risk adjustment. However, these process indicators have limitations inherent to the methods by which they were derived, and can change over time as new knowledge is accumulated. Thus, assessing patient outcomes 4 , 42 , 47 , 48 , 55 , 72 , 73 , 75 may be more valuable than merely comparing the process of generalist vs specialty care.
Due to a dearth of data on costs, future studies should include some form of economic analysis. While as a group specialists often outperform generalists in some areas of medical practice, this does not imply that any given specialist will provide better care than any particular generalist. Variations in quality of care among generalists and even among specialists are often larger than variations between the 2 groups. Also, while as a group specialists' knowledge base and practice patterns are superior to those of generalists in certain instances, the magnitude of these differences and their overall effects on morbidity and mortality are likely small, compared with the sequelae of deficiencies in disease management and preventive medicine common to all physicians, generalists and specialists alike.
Equally important are the deficiencies common to all physicians in the provision of preventive care. These include underimmunization; inadequate use of cancer and other screening tests; infrequent, poor health counseling; and inadequate identification and treatment of psychosocial problems. These deficiencies affect all patients and should be particularly distressing to generalists, since they lie in those areas in which generalists have traditionally claimed special expertise.
Current levels of child and adult vaccination in the United States are less than half the levels in other industrialized countries. Physicians also significantly overestimate their performance of common cancer screening tests. Physicians are frequently unsuccessful in identifying alcohol and drug abuse, despite its high prevalence in both inpatient and outpatient settings. Physicians are frequently neglectful with respect to counseling patients in other areas, including diet, , exercise, stress reduction, sun exposure, 64 preconception health, 68 breast-feeding, use of seat belts and helmets, and firearm safety.
More than three quarters of parents want physicians to discuss substance abuse, sexuality, mental health issues, nutrition, and general medical issues with their teenagers. In the public's opinion, along with inadequate attention to costs of treatment, physicians' worst deficiencies lie in communication skills and in the recognition and management of psychosocial contributors to health and illness.
Often, physicians know little about their patients' social histories, and fail to recognize their psychosocial needs 43 , , and functional disabilities. Physicians often deal poorly with suffering and dying patients, neglecting to provide essential information about cardiopulmonary resuscitation during discussions of code status, or failing to elicit patients' concerns regarding end-of-life issues. Yet not all data show that physicians ignore counseling.
In turn, their patients participate more actively in their own care by expressing opinions and asking questions. On the other hand, overutilization can also negatively affect quality of care. Overtesting, without an appreciation for the test characteristics, can lead to further unwarranted interventions, including those that may harm the patient either physically or psychologically.
In a cross-sectional survey, Wilcox et al found that almost one quarter of community-dwelling elderly were receiving at least one contraindicated prescription drug, placing them at risk for adverse effects such as sedation and cognitive impairment. On the other hand, high rates of inappropriate care and geographic variation in care patterns that do not affect clinical outcomes have also been extensively documented. In cardiology, while certain drugs are clearly underused, coronary angiography and revascularization, expensive and invasive procedures, may be overused.
Privately insured patients are more likely to receive angiography, angioplasty, and bypass grafting than Medicaid or uninsured patients. Patients in high-use regions of the country were older, had less severe angina, and were treated less intensively medically than patients in low-use sites. Blustein found that the availability of cardiac services in the hospital to which patients presented strongly influenced the likelihood of their use in the period following acute myocardial infarction; this was unlikely due to selection bias.
Similarly, Every et al discovered that after adjustment for clinical factors, the availability of on-site catheterization facilities was associated with a higher likelihood that a patient would undergo angiography. While no short-term mortality benefit was associated with the greater use of angiography, their study lacked adequate statistical power to detect either short- or long-term mortality benefits. Thus, overuse of cardiac procedures appears likely.
While large US geographic variations in the use of angiography do not correlate with mortality or health-related quality of life, comparisons of the coronary procedure rates in Canada and the United States suggest that the greater rates in the United States may be associated with decreases in anginal symptoms. Within the United States, greater physician and hospital experience with cardiovascular procedures leads to better outcomes.
Interestingly, just as some specialists reach for different technologies first in treating patients, they tend to withdraw these same technologies first when withdrawing care from the terminally ill. Large geographic variations have also been noted in the use of grafts vs fistulae for patients undergoing hemodialysis.
Payment mechanisms may also affect utilization. Patients who receive care in health maintenance organizations are half to one fourth as likely to be operated on as patients in the fee-for-service sector, usually with no major outcome differences. Thus, a number of factors can contribute to overuse, including numbers of specialists, education, differences in local practice styles, uncertainty or skewed beliefs regarding the benefits of an intervention, eagerness to adopt new and unproved tests or procedures, patient race and socioeconomic status, patient choice, and, under fee-for-service, physician financial incentives.
With increasing capitation under managed care, the influence of the latter incentive should diminish. Obviously, specialists should not be held responsible entirely for the high-documented rates of inappropriate interventions, since primary care physicians, through the referral process, play some role in determining who eventually receives these interventions.
Furthermore, inadequate patient education by physicians and lack of patient involvement in the informed consent process may lead patients to accept more readily procedures they might have refused otherwise. While certain differences point to correctable deficiencies of generalists, these differences are not as striking or clinically important as the deficiencies in disease management, preventive care, and health maintenance common to all physicians. Primary care involves your primary healthcare provider.
You see them for things like acute illnesses, injuries, screenings, or to coordinate care among specialists. Secondary care is the care of a specialist. These specialists may include oncologists, cardiologists, and endocrinologists. Tertiary care is a higher level of specialized care within a hospital. Similarly, quaternary care is an extension of tertiary care, but it is more specialized and unusual.
The majority of the time, you'll only receive primary or secondary care. However, when you have a severe injury, condition, or disease, your doctor will move you to higher levels.
Understanding the levels of care will help you navigate the medical system and receive the care you need. Sign up for our Health Tip of the Day newsletter, and receive daily tips that will help you live your healthiest life. Shi L. The impact of primary care: a focused review. Scientifica Cairo. Primary and tertiary health professionals' views on the health-care of patients with co-morbid diabetes and chronic kidney disease - a qualitative study. BMC Nephrol.
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I Accept Show Purposes. Table of Contents View All. Table of Contents. Primary Care. Secondary Care. Tertiary Care. Quaternary Care. The types of quaternary care include: Experimental medicine and procedures Uncommon and specialized surgeries. Was this page helpful?
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