Domhnall MacAuley
is a CMAJ Associate Editor and a professor of primary care in Northern Ireland, UK. He is currently attending the North American Primary Care Research Group (NAPCRG) annual meeting in Colorado Springs, CO.
Not many primary care doctors have an 8 billion dollar budget. Mitch Katz, who gave the opening keynote address at NAPCRG 2016, is director of the Los Angeles County Health Agency which combines the Departments of Health Service, Public Health and Mental Health into one service. He continues to see patients and described how he had become so specialised in his career in a primary care AIDs clinic in San Francisco, that he found returning to generalist practice extremely difficult. When he focused on AIDS he was on top of his topic like any specialist, but, as a generalist, he had to cope with anything from a heart attack to broken heart.
Los Angeles, until recently, had no ambulatory care and he described the situation he inherited where most patients accessed health care through the ER room creating a negative cycle of referral because you could not access investigations from primary care. Each visit generated a new attendance with a comprehensive workup and repeated investigations (e.g. multiple CT scans) creating a huge drain on resources. But, when he wanted to start a primary care service, he was told there was no money. An additional and unexpected problem was that the reimbursement rates for radiology was so good that it helped fund hospitals.
Mitch created an ambulatory care network and, in developing primary care services, he focused on three components: placing 350,000 patients with primary care homes; creating a registry; and ensuring that everyone was working at the top of their licence (eg empowering nurses to take on more clinical tasks). He introduced electronic consultations between specialists and generalists which not only helped collaboration, but also ensured that primary care doctors learned from discussing their patients directly with specialists.
One particularly interesting innovation was in housing. Homeless patients could not leave hospital as they had nowhere to go; however, if these patients were kept in hospital for no acute reason they did not attract a payment. If the hospital could discharge these patients they could admit a patient who attracted funding. So, they invested in housing and, to date, have moved more than 1,000 medically complex patients into independent housing and, on one occasion were able discharge 120 patients out at one time. They also looked at food insecurity, providing not just for those who could not afford food, but providing the right food for diabetics, for example. The future, as with many aspects of health care in the US at present, is uncertain and, when asked about the recent election results, he said it was not good news for ambulatory care and was bad news for patients.
Often the poster presentations include some gems. I spoke to Larry Green, who as one of the most accomplished North American primary care researchers, has been to many meetings. He was very impressed with the quality of research presented. He considered the overall standard had increased greatly but still felt there were still some research areas underrepresented and, in particular he singled out prognosis research.
One programme of research that stood out for me was by McGill 2016 Vanier Scholar, Claire Godard-Sebillotte. She described a series of research studies looking at the reasons why patients with dementia attend emergency departments. Her work includes a systematic review and meta analysis of randomised controlled trials of interventions to reduce hospital use, together with a synthesis of qualitative studies looking at the reasons why people attend. She has registered the study with Prospero and published her protocol so its work in progress. There were, remarkably, few intervention studies, and as we deal with an ageing population, this will be an increasingly important research area.
In contrast, one of the most unusual studies looked at the effect of reciting hexameter poetry in late life depression. I asked Klea Bertakis about her study and if prayer recitation may have a similar benefit. Together with with the acknowledged benefits of being part of a community, such as a church group, it’s intriguing to reflect that perhaps previous generations may have known more about healthy aging than we thought!
One of the most encouraging and interesting sessions was entitled the Distinguished Trainee Presentations. Kyleigh Schraeder’s intriguing title suggested that family doctors are “out of the loop” in managing their paediatric patients with mental health problems. There was little integration of physical and mental health and, indeed, parents were surprised that, in her research, she was asking about their family doctor at all. Clearly there was a need for more collaboration – they were simply not talking.
Christopher Harrison asked a resounding question: “Why do Female GPs earn less than their male colleagues?”. The pay gap in all professions is about 18% but a GPs pay is not based on seniority or negotiation skills, so theoretically, their pay should be equal. In fact, the difference was 33%. Looking at data from the Beach project, male GPs worked more hours but the content of their work was also different. Female GP’s consultations were longer and addressed more problems per encounter, including more social and psychological issues. It was, he concluded, a different style of medicine – the type of medicine we would aspire to.
And, the most original study must be Alia Moore’s work where she intends to give ex- prisoners a camera on release to record photographically the factors affecting their health. I look forward, in particular, to outcomes of this study and hope that journals will find a way to publish it in a way that captures its unique nature.
The North American Primary Care Research Group Annual Meeting is being held from November 12th to 16th 2016 in Colorado Springs, CO. CMAJ is a co-sponsor of the meeting.