Primary Care America's Health in a New Era (1996) / Chapter Skim
Currently Skimming:
The Nature of Primary Care
The Nature of Primary Care
Pages 76-103
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From page 76... ...
Primary care could be considered the care provided to these 250 individuals care that is positioned between self-care and the remainder of the clinical enterprise. Primary care also includes carefully defined efforts to promote health and prevent disease in the entire population in coordination with public health activities.
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From page 77... ...
CONTENT OF PRIMARY CARE The Large Majority of Health Care Needs The committee's definition of primary care stresses that primary care clinicians address a large majority of the problems people bring to the health care system. The content of primary care has been described in multiple ways, and the committee examined data from national surveys conducted in the United States and other countries.
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From page 78... ...
General medical examination 7.2 7.2 2. Acute upper respiratory tract 6.2 13.4 infection 3.
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From page 79... ...
Episodes of Primary Care To measure accurately the effects of primary care, data systems and research methods must be able to reflect the co-occurrence of health problems and the longer time frames needed to evaluate the integrative functions of primary carecomprehensiveness, continuity, and coordination. However, in primary care, recording the content of care using standard coding systems such as the International Classification of Diseases or the Diagnostic and Statistical Manual (for mental health)
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From page 80... ...
The Netherlands Transition Project, which uses the International Classification of Primary Care (ICPC) , provides detailed information on the content of family practice in the form of episodes of care for age- and sex-specific groups (Lamberts and Wood, 1987; Lamberts et al., 1993; Lamberts and HofmansOkkes,1996~.
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From page 81... ...
Biomedical and Social Sciences Biomedical Sciences Biomedical knowledge is as important in primary care as it is in secondary or tertiary care. Primary care draws from biology to provide diagnostic, prognostic, and therapeutic services to help acutely and chronically ill patients.
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From page 82... ...
In addition to knowledge derived from the basic and biomedical sciences and randomized clinical trials, primary care clinicians use results of population-based epidemiological studies that examine risk factors for disease and information from outcomes and effectiveness studies of treatments used by community-based clinicians. Clinicians supplement their knowledge of mechanisms of disease and therapies and their clinical experience with information about the probabilities that (a)
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From page 83... ...
Furthermore, the referral specialist often sees patients for a single visit and has only limited knowledge of the patient's background or history; by contrast, the primary care clinician often has an ongoing relationship with the patient and has relevant knowledge of the patient's history and situation. The specialist is frequently expected to reach an immediate and definitive resolution of a health concern; the primary care clinician can observe the patient over time, watching for evolution that indicates greater (or lesser)
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From page 84... ...
If primary care clinicians tend to refer when tests are equivocal or symptoms do not resolve with observation or treatment, a referral practice would be enriched with patients who have intermediate probabilities of disease that is, the diagnostic puzzles of medicine. Said differently, referral practice consists of patients with a higher probability of having particular diseases than would be expected in primary care practices.
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From page 85... ...
The fields of decision analysis, risk communication, and health behavior have all contributed to a better understanding of how to assess and convey information in primary care practice; work by Mulley, Wennberg, and others in the area of shared decisionmaking has been especially influential (Mulley, 1991; Kasper et al., 1992~.
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From page 86... ...
When a patient with a mental disorder presents to a primary care clinician, it is usually by means of a physical complaint. Primary care patients with mental diagnoses whether or not they meet formally defined diagnostic criteria show profound functional impairment.
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From page 87... ...
These biases, whether attributable to underrecognition or underreporting by primary care clinicians, produce remarkable underestimates of mental health problems and subsequent care for these problems in primary care; for example, the diagnostic cluster of depression and anxiety accounts for only about 2.5 percent of nonreferred ambulatory visits according to the NAMCS data (see Table 4-1~. By contrast, other sources estimate that 10 to 20 percent of the general population will consult a primary care clinician for a mental health problem in the course of a year.
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From page 88... ...
As with the issues of mental health noted above, the coordination of primary care personal services with public health programs is examined in more detail in Chapter 5. The Power of Information The knowledge base that is relevant to a large majority of the problems that people bring to their primary care clinicians is large and constantly evolving.
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From page 89... ...
To explore this possibility, the committee engaged in a data collection and analysis effort based on national survey information and specially generated information from selected health maintenance organizations and managed care entities (Hofmans-Okkes and Lamberts, 1995~. This appendix presents a brief explanation of the Netherlands Transition Project approach and gives an illustrative set of data on one age-sex cohort (women ages 25 to 44~; it also includes a short discussion of the analyses done using U.S.
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From page 90... ...
Typically, analyses involving the top 20s will account for a proportion of episodes of care that exceed, often by wide margins, 30 percent of all episodes. Thus, the top 20 new episodes give a global impression of the magnitude and diversity of acute personal health care needs; the top 20 old episodes indicate the burden of chronic illness and long-term episodes or follow-up (including for health maintenance and preventive care)
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From page 91... ...
The U.S. Data The committee examined information from the National Ambulatory Medical Care Survey (NAMCS)
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From page 92... ...
In addition, the committee requested and received special episode data runs from three managed care organizations (of six approached; these three were the only ones able to produce the requested episode-oriented information from their internal records)
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From page 93... ...
. Among the top 20 entries, as might be expected, pregnancy and family planning episodes appear frequently, as do certain health maintenance diagnoses (e.g., Pap smears)
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From page 94... ...
Provide initial episode ongoing 274 18.1 1.0 (reproductive functions) Advice/health education 264 17.4 0.9 (reproductive functions)
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From page 95... ...
Several of the diagnoses appear in both new and ongoing episodes. Among them are family planning and pregnancy (which have rates of 95.0, 18.2, and 11.2 per 1,000 enrolled women)
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From page 96... ...
SOURCE: Hofmans-Okkes and Lamberts, 1995 chronic conditions. Among the latter are hypertension, irritable bowel syndrome, and asthma; quite notable is the rate of affective mental disorders (depressive disorders and anxiety, nervousness, and tension, which have rates of 6.7 and 6.3, respectively)
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From page 97... ...
The order of types of episodes is somewhat arbitrary, in that it groups preventive services, various types of gynecologic or obstetric services, a broad set of acute upper respiratory conditions, widely prevalent chronic conditions, and a wide array of other conditions that proved to be important in at least one of these data sets. The data are shown as rates per 1,000 women.
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From page 98... ...
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From page 99... ...
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From page 100... ...
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From page 101... ...
The other was to shed some light, if possible, on the epidemiology of "the great majority of health care needs" that the committee points to in its definition of primary care. The data from the Netherlands Transition Project were used as a analytic prototype.
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From page 102... ...
Schappert, S.M. National Ambulatory Medical Care Survey: 1991 Summary.
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From page 103... ...
Guide to Clinical Preventive Services: An Assessment of the Effectiveness of 169 Interventions.
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