Epidemiology of Primary Care and relation to preventive medicine - public health

Epidemiology of Primary Carein relation to preventive medicine - public healthCMG Buttery MB BS MPH2012this set of slides discusses the distribution of problems in primary care: the epidemiology of care rather than the practice, which was discussed in the previous set of slides.1Figure 1. Percent of office visits by physician specialty: United States, 2000

The data on these slides comes from studies I conducted 30 years ago at Eastern Virginia medical school, and through the continuing series of studies since then from the NCHS, the National Ambulatory Medical Care Survey(NAMCS). There has been no significant change in the distribution of care by type of practitioner or major problems in the last 40 years. The pie chart shows that over 60% of care is provided in the offices of general and family physicians, internal medicine physicians and pediatricians210 Advance Data No. 328 + June 5, 2002Table 1. Number, percent distribution, and annual rate of officevisits with corresponding standard errors, by selected physicianpractice characteristics: United States, 2000Physician practice characteristicNumber of visitsin thousandsAll visits 823,542Physician specialtyGeneral and family practice 198,578Internal medicine 125,556Pediatrics 103,734Obstetrics and gynecology 65,135Orthopedic surgery46,155Ophthalmology 42,735Dermatology34,509Psychiatry 28,864Cardiovascular diseases 21,598Urology 18,703General surgery 16,897Otolaryngology 16,399Neurology 8,411All other specialties 96,269

>50% of ALL office visits are to primary care physicians.

Slides three through six; from the advance data presentations of NAMCS, show distribution of visits by different parameters to help explain who gets what kind of care from whom.3Advance Data No. 328 June 5, 2002Table 3. Number, percent distribution, and annualrate of office visits by patients age, sex, and race:United States, 2000Patients age, sex, and race Number of visits in thousands

All visits 823,542 AgeUnder 15 years 142,4661524 years 67,1722544 years 196,8334564 years 216,7836574 years 102,44775 years and over 97,84216 Advance Data No. 328,June 5, 2002Table 9. Number and percent distribution of office by the 20 principalreasons for visit most frequently mentioned by patients, United States, 2000Number of visits inPrincipal reason for visit and RVC code1 thousandsAll visits 823,542General medical examination* X10063,952Progress visit, not otherwise specifiedT80032,776Cough S44022,360Routine prenatal examination* X20522,085Postoperative visit T20521,178Symptoms referable to throat S45517,519Skin rash S86013,365Vision dysfunctions S30512,965Knee symptoms S92512,533Back symptoms S90512,464Well-baby examination* X10512,457Stomach pain, cramps, and spasms S54512,275Medication, other and unspecified kinds T11511,424Earache or ear infection S35511,288Hypertension D51010,398Depression S11010,043Headache, pain in head S2109,320Nasal congestion S4008,857Chest pain and related symptoms S0508,833Fever S0108,801All other reasons 488,650

*Prevention visitsAdvance Data No. 328,June 5, 2002Table 16. Number and percent of office, by therapeuticand preventive services ordered or provided, United States, 2000Number of Therapeutic and preventive visitsin services ordered or provided thousandsAll visits 823,542None 515,550Counseling/education Diet 26,988Exercise 80,839Injury prevention 24,610Growth/development21,460Stress management 18,403Prenatal instructions 18,396Mental health 18,221Tobacco use/exposure 18,213Breast self-examination 17,827Skin cancer prevention 14,311Family planning/contraception 9,564HIV/STD transmission 5,190Other therapyComplementary and alternativemedicine 31,589Physiotherapy22,273Psycho-pharmacotherapy19,947Psychotherapy 18,669Table 26. Mean time spent with physician by physician specialty: United States, 2000Mean time spent with physician (Mins.)

Physician specialtyAll visits 18.9Psychiatry 36.0Neurology 28.0Cardiovascular diseases 21.5Internal medicine 19.7General surgery 19.0Obstetrics-gynecology 18.2Orthopedic surgery17.1General, family practice 17.0Ophthalmology 16.9Otolaryngology 16.8Urology 16.2Dermatology15.8Pediatrics 15.4All other specialties 23.5Which is to most primary care physicians amount about 6000 visits a year for some 2000 patients or on the average 3 visits per patient.7PRIMARY CARE PROBLEMS IDENTIFIED BY PRIMARY PRACTITIONERS

Prepared for NAPCRAG meeting in 1984TOTAL NUMBER OF PROBLEMS IDENTIFIED (have ICD code)TOTAL COMMON PROBLEMS as PERCENT OF TOTAL PROBLEMS FP591159/26.9GIM520147/28.3PED35390/25.5OBG27769/24.9

The data for this table was prepared 25 years ago using data from the first NACMS survey and shows the relationship between common problems [problems which required at least six visits a year] as a percentage of all visits to the doctor's office using the ICD(A) code as the type of visit label. This has not changed over the last 30 years. The visits to family practitioners and internists were very similar, while those for pediatricians was mostly for well children where the mothers were worried. The obstetricians cared for a very limited set of visits for very specific conditions.

8NUMBER AND PROPORTION OF COMMON PROBLEMS SEENBY PHYSICIAN B AS A SUBSET OF TOTAL COMMON PROBLEMSSEEN BY PHYSICIAN APhysician APhysician BFPGIMPEDOBGFP159/100110/73.874/83.141/61.2GIM110/69.2147/10053/59.633/49.3PED74/46.953/35.690/10027/40.3OBG41/25.833/22.127/30.369/100

Slide nine shows cross-correlation of the number of visits made by the physician B as a proportion of visits in the succeeding columns of physicians. Of the 159 common problems seen by family doctor 110 of these were also seen in an internists office and constituted 74% of the internists practice. However only 75 of common problems seen by family Drs. were also seen in the pediatricians office.Slide 10 through 13 show problems identified in the NACMS Data that were amenable to preventive intervention.

9Types of PreventionPrimary Before signs or symptoms of diseaseImmunizationDietExerciseAspirin to reduce stroke events

Slides 10 through 13 show problems identified in the NACMS Data that were amenable to preventive intervention.10Prevention (Continued)SecondarySigns and symptoms present but earlyLower Blood PressureReduce SmokingReduce WeightReduce StressReduce Salt IntakeINH for TB InfectionPrevention (Continued)TertiaryLate disease, intent to delay progressPhysical Therapy after InjuryAnticoagulant after StrokeWeight Reduction for Morbid ObesityHAART Therapy for PWATamoxifen after Breast Cancer SurgeryInsulin Pump for Type 1 DiabeticPROPORTION OF OFFICE VISITS FOR DIAGNOSES AMENABLE TO PRIMARY OR SECONDARY PREVENTION

MDPrimSecFP 129.8 5.4GIM 31.9 l0.6PED 31.8 0.2OBG 54.1 0.9

Slide 14 and 15 highlight suggest why enhancing prevention practices could improve the health of the patients by linking primary care and public health resources as well as improving practice data sets with electronic systems.13How do we improve the links between Primary Care and Public Health/PreventionPay for Prevention ServicesAdd Physician Extenders to PracticeNP, PA, H.Ed., MH CounsellorUse of Computerized Records that Remind need of ImmunizationsRemind Need for Routine ManagementProvide Health Ed. MaterialComputer links to patients.

PC PH Prevention LinksCloser Health Department Practicing physician ties.Weekly or monthly surveillance reportsDatabases of Community Health StatusPrevention talks at Hospital meetingsEpidemiologic Surveys of patient recordsCASA/CDCPeriodic review of death records with Rx for prevention activitiesPlace PHNs in Physicians offices How many Doctors?Current US population: Approximately 300Mn.

AFP Recommended patient load: 1 FP/2000 patientsThe last four slides discuss the need for more primary care physicians in the U.S.A. 2000 patients per PC Physician as an easy number to calculate, although the Academy of Family Practice has reduced the suggested number of patients per physician from 2000-1800 over the last few years because of the time taking for increasing paperwork in the doctors office. The AAFP recommendations increase the need for PC MDs/NPs.

16How Many Doctors -IIFor 300 Million People: 150,000 FPs.Assume 48 work weeks per MDAssume 10% will be in nonproductive positions teaching.Need =200,000Outside the US maximum ratio ofSpecialist to PCPs is 1:1How Many Doctors IIIMaximum number of physicians needed for Primary care

400,000

According to AMA practicing non-federalPhysicians 814776 non-federalHow Many Doctors - IVMost physicians are in Patient Care (80.0%). Patient Care includes: Office-Based physiciansFull-Time Hospital Staff (9.2%), and Residents/Fellows (14.0%). Physicians not in Patient Care are in Other Professional Activity, which includes: Administration (1.9%), Teaching(1.2%), Research (1.7%), and Other (0.5%). None of these percentages has changed significantly over the last 30 years.

From these calculations it might appear we have more physicians than we need, but unfortunately most physicians today are specialists who see a much smaller number of patients per day with a very limited diagnostic spectrum, than the primary care physician, leaving many potential patients across the country without access to any care except for the local emergency department, if there is one. This problem is compounded by physicians working shorter hours per week and ordering more tests because of the short time they can spend with patients, and the increased paperwork required by insurance companies and the ACA.19